WSR 98-19-014

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Medical Assistance Administration)

[Filed September 4, 1998, 3:07 p.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 96-07-042.

Title of Rule: Chapter 388-543 WAC, Medical equipment, prosthetics, orthotics, and medical supplies (new), WAC 388-86-100 Durable medical equipment, prosthetic devices, and disposable/nonreusable medical supplies (amend), WAC 388-86-200 Limits on scope of medical program services (amend), and WAC 388-86-110 X-ray services (repeal).

Purpose: To add payment methodology to Medical Assistance Administration rules regarding durable medical equipment.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

Statute Being Implemented: Chapters 74.08, 74.09 RCW.

Reasons Supporting Proposal: To comply with ruling in Failor's Pharmacy v. Department of Social and Health Services/lawsuit.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Ann Myers, Medical Assistance Administration, 617 8th Avenue S.E., Olympia, WA 98504, (360) 586-2337.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is necessary because of state court decision, citation: Failor's Pharmacy v. Department of Social and Health Services, 125 Wn.2d 488, 886 P.2d 147(1994).

Explanation of Rule, its Purpose, and Anticipated Effects: This rule adds payment methodology for durable medical equipment to Medical Assistance Administration rules. The purpose is to codify the payment methodology that is currently contained in billing instructions and numbered memos.

Proposal Changes the Following Existing Rules: The new WAC codifies the payment methodology that is currently reflected in billing instructions and numbered memos.

No small business economic impact statement has been prepared under chapter 19.85 RCW. This proposal does not affect businesses.

RCW 34.05.328 does not apply to this rule adoption. This rule does not change policy, it codifies existing policy. A cost-benefit analysis has been prepared. To obtain a copy, contact Ann Myers, Medical Assistance Administration, 617 8th Avenue S.E., Olympia, WA 98504.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on October 27, 1998, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by October 15, 1998, phone (360) 902-7540, TTY (360) 902-8324, e-mail pwall@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, Acting Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by October 27, 1998.

Date of Intended Adoption: November 1, 1998.

September 2, 1998

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

SHS-2472.1

Chapter 388-543 WAC

MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES

NEW SECTION

WAC 388-543-1000 Definitions. "Artificial limb" - See "prosthetic device."

"Augmentative communication device (ACD)" means a medical device that transmits or produces messages or symbols, either by voice output or in writing, in a manner that compensates for the impairment or disability of a client with severe expressive or language communication and comprehension disorders. The communication device may use mechanical or electrical impulses to produce messages or symbols that supplement or replace speech.

"Bed-confined" means being in bed twenty hours or more per day, as required by a medical condition.

"By Report (BR)" means a method of reimbursement for covered items, procedures, and services for which the department has no set maximum allowable fees.

"Chronic intractable pain" means pain that is of long duration and has been difficult to ease, remedy, or cure.

"Date of delivery" means the date the client actually took physical possession of an item or equipment.

"Disposable supplies" means supplies which may be used once, or more than once, but are time limited.

"Durable medical equipment (DME)" means equipment that:

(1) Can withstand repeated use;

(2) Is primarily and customarily used to serve a medical purpose;

(3) Generally is not useful to a person in the absence of illness or injury; and

(4) Is appropriate for use in the client's place of residence.

"Duration of therapy" means the estimated span of time that a client will need a particular type of therapy for a specific medical problem.

"Expedited prior authorization" means the request process for selected durable medical equipment in which providers use a set of defined criteria acceptable for a particular DME request in lieu of calling or writing MAA for prior authorization.

"Fleet wheelchair" means a wheelchair that comes standard from the manufacturer and does not require structural frame modification to meet a client's unique medical needs. These wheelchairs can be used by other nursing facility residents. It may be appropriate to add equipment such as solid seats, solid backs, wedge cushions, legrests, or armrests to a standard wheelchair in order to meet the needs of a particular resident. These types of additions generally do not change the basic structure; therefore, these wheelchairs are considered fleet wheelchairs and are included in the nursing facility's per-patient-day rate under chapter 74.46 RCW and chapter 388-96 WAC.

"Nonreusable supplies" are disposable supplies which are used once and discarded.

"Orthotic device" means a corrective or supportive device that:

(1) Prevents or corrects physical deformity or malfunction; or

(2) Supports a weak or deformed portion of the body.

"Personal or comfort item" means an item or service which primarily serves the comfort or convenience of the client. These items or services do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member.

"Positioning equipment" means equipment that promotes fixed, corrected body alignment and is tailored to a specific client's physical needs.

"Prosthetic device" means a replacement, corrective, or supportive device prescribed by a physician or other licensed practitioner of the healing arts, within the scope of his or her practice as defined by state law, to:

(1) Artificially replace a missing portion of the body;

(2) Prevent or correct physical deformity or malfunction; or

(3) Support a weak or deformed portion of the body.

"Reusable supplies" are supplies which are to be used more than once.

"Scooter" means a federally-approved, motor-powered vehicle that:

(1) Has a seat on a long platform;

(2) Moves on either three or four wheels;

(3) Is controlled by a steering handle; and

(4) Can be independently driven by a client.

"Specialty bed" means a pressure reducing support surface, such as foam, air, water, and gel mattress or overlay.

"Structurally modified wheelchair" means a wheelchair that requires structural frame modifications from the manufacturer, resulting in an additional cost that would be passed on to the vendor. Such structural frame modifications would result in the wheelchair meeting the unique medical needs of a client, and would not be usable by most other clients without additional structural frame modifications.

"Three- or four-wheeled scooter" means a three- or four-wheeled vehicle meeting the definition of scooter (see "scooter") and which has the following minimum features:

(1) Rear drive;

(2) A twenty-four volt system;

(3) Electronic or dynamic braking;

(4) A high to low speed setting; and

(5) Pneumatic rear tires.

"Trendelenburg position" means a position in which the patient is lying on his or her back on a plane inclined thirty to forty degrees. This position would make the pelvis higher than the head, with the knees flexed and the legs and feet hanging down over the edge of the plane.

"Usual and customary charge" means the amount the provider typically charges to fifty percent or more of his or her non-Medicaid clients, including clients with other third-party coverage.

"Warranty-wheelchair" means a warranty according to manufacturers guidelines of not less than one year from the date of purchase.

"Wheelchair - manual" means a federally-approved, nonmotorized wheelchair that can be independently propelled by a client using his or her upper extremities and fits one of the following categories:

(1) Standard:

(a) Usually is not capable of being modified;

(b) Accommodates a person weighing up to two hundred fifty pounds; and

(2) Lightweight:

(a) Composed of lightweight materials;

(b) Capable of being modified;

(d) Usually has a warranty period of at least three years.

(3) High strength lightweight:

(a) Is usually made of a composite material;

(b) Is capable of being modified;

(d) Has an extended warranty period of over three years; and

(e) Accommodates the very active person.

(4) Hemi:

(a) Has a seat-to-floor height lower than eighteen inches to enable an adult to propel the wheelchair with one or both feet; and

(b) Is identified by its manufacturer as "hemi" type with specific model numbers that include the "hemi" description.

(5) Pediatric: Has a narrower seat and shorter depth more suited to pediatric patients, usually adaptable to modifications for a growing child.

(6) Recliner: Has an adjustable, reclining back to facilitate weight shifts and provide support to the upper body and head.

(7) Tilt-in-space: Has a positioning system which allows both the seat and back to tilt to a specified angle to reduce shear or allow for unassisted pressure releases.

(8) Heavy Duty:

(a) Specifically manufactured to support a person weighing up to three hundred pounds; or

(b) Accommodating a seat width of up to twenty-two inches wide (not to be confused with custom manufactured wheelchairs).

(9) Rigid: Is of ultra-lightweight material with a rigid (nonfolding) frame.

(10) Custom heavy duty:

(a) Specifically manufactured to support a person weighing over three hundred pounds; or

(b) Accommodates a seat width of over twenty-two inches wide (not to be confused with custom manufactured wheelchairs).

(11) Custom manufactured specially built:

(a) Ordered for a specific client from custom measurements; and

(b) Is assembled primarily at the manufacturer's factory.

"Wheelchair - power" means a federally-approved, motorized wheelchair that can be independently driven by a client and fits one of the following categories:

(1) Custom power adaptable to:

(a) Alternative driving controls; and

(b) Power recline and tilt-in-space systems.

(2) Noncustom power, does not need special positioning or controls and has a standard frame.

(3) Pediatric: Has a narrower seat and shorter depth that is more suited to pediatric patients. Pediatric wheelchairs are usually adaptable to modifications for a growing child.

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NEW SECTION

WAC 388-543-1100 Scope of coverage and coverage limitations. The federal government deems medical equipment and related supplies, prosthetics, orthotics; and medical supplies as optional services under the Medicaid program, except when prescribed as an integral part of an approved plan of treatment under the home health program. The department may reduce or eliminate coverage for optional services, consistent with legislative appropriations.

(1) Medical equipment and related supplies, prosthetics, orthotics, medical supplies, related services, repairs and labor charges are covered when they are:

(a) Within the scope of an eligible client's medical care program;

(b) Determined by the medical assistance administration (MAA) to be medically necessary; and

(c) Within accepted medical or physical medicine practice standards defined by the MAA and consistent with the client's medical diagnosis.

(2) Medical equipment and related supplies, prosthetics, orthotics, medical supplies, related services, repairs and labor charges are not reimbursed under fee-for-service when the client is:

(a) An inpatient hospital client;

(b) Eligible for both Medicare and Medicaid, and is staying in a nursing facility in lieu of hospitalization;

(d) Enrolled in a risk-based managed care plan that includes coverage for such items and/or services.

(3) Only those medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services, repairs and labor charges, listed in MAA's billing instructions and numbered memoranda, are covered unless prior authorized as described in WAC 388-543-1700 and 388-543-1800.

(4) The decision to purchase or rent medical equipment for a client, or pay for repairs to client-owned equipment is made by MAA based on the least costly and/or equally effective alternative.

(5) Replacement batteries for purchased DME equipment are covered only when medically necessary for:

(a) Wheelchairs;

(b) Transcutaneous electrical nerve stimulator units (TENS); and

(6) The following categories of medical equipment and supplies are covered only when they are medically necessary; prescribed by a physician or other licensed practitioner of the healing arts; are within the scope of his or her practice as defined by state law, and are subject to the provisions of this chapter and related WACs:

(a) Equipment and supplies prescribed in accordance with an approved plan of treatment under the home health program;

(b) Wheelchairs and other durable medical equipment;

(d) Surgical/ostomy appliances and urological supplies;

(e) Bandages, dressings, and tapes;

(f) Equipment and supplies for the management of diabetes; and

(g) Other medical equipment and supplies, as listed in MAA published issuances.

(7) A "by report" item, procedure or service is evaluated for its medical appropriateness and reimbursement value on a case-by-case basis.

(8) Nursing facilities are responsible for providing their residents with medically necessary equipment, such as wheelchairs, specialty beds, augmentative communication devices, lifts, and positioning equipment in accordance with chapters 388-96 and 388-97 WAC.

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NEW SECTION

WAC 388-543-1200 Eligible providers. (1) A provider of medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services to a MAA client must:

(a) Have the proper business license;

(b) Have appropriately trained qualified staff;

(d) Be certified, licensed and/or bonded if required, to perform the services billed to the department.

(2) Fee-for-service reimbursements may be made by MAA for medical equipment and related supplies, prosthetics, orthotics, repairs, medical supplies, and related services to qualified participating medical care providers as follows:

(a) Durable medical equipment providers for durable medical equipment and related repair services.

(b) Medical equipment dealers, pharmacies, and home health agencies under their medical vendor provider number for medical supplies, unless otherwise prohibited in any subsection of this section.

(c) Licensed prosthetics and orthotics providers, who are accredited by the American Board for Certification in prosthetics and orthotics, except for medical equipment dealers and pharmacies for selected orthotics that do not require specialized skills to provide.

(d) A physician may be paid separately for medical equipment and supplies provided in a physician's office, subject to the provisions in the department's resource based relative value scale (RBRVS) fee schedule.

(3) A provider found in violation of program regulations and policies will be terminated from Medicaid participation, as described in WAC 388-87-0005(3) and 388-87-007(7).

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NEW SECTION

WAC 388-543-1300 Noncovered medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services. Unless required under the early and periodic screening, diagnosis and treatment (EPSDT)/healthy kids program, included as part of a managed care plan service package, included in a waivered program, or part of one of the Medicare programs for qualified Medicare beneficiaries, services and equipment which are specifically excluded from the fee-for-service scope of coverage include:

(1) Services, procedures, treatment, devices, drugs, or application of associated services which the department or the Food and Drug Administration (FDA) and/or the Health Care Financing Administration (HCFA) consider investigative or experimental on the date the services are provided;

(2) More costly services or equipment when less costly, equally effective services or equipment, as determined by the department, are available;

(3) Any service specifically excluded by statute;

(4) Wheelchair features and options not considered by the department to be medically necessary or essential for wheelchair use. These features and options include, but are not limited to:

(a) Speed conversion kits;

(b) Tie-down restraints;

(d) Warning devices, such as horns and backup signals;

(e) Canopies, including those for strollers and other equipment;

(f) Clothing guards to keep clothes from getting muddy (similar to mud flaps for cars);

(g) Identification devices (such as labels, license plates, name plates); and

(h) Attendant controls (remote control devices).

(5) Nonmedical equipment and supplies and related services including, but not limited to:

(a) Environmental control devices, such as air conditioners, air cleaners/purifiers, dehumidifiers, portable room heaters or fans, heating or cooling pads;

(b) Exercise classes or equipment such as therapy mats, bicycles, tricycles, stair steppers, weights, trampolines;

(d) Ergonomic equipment;

(e) Racing strollers/wheelchairs and recreational equipment;

(f) Wheeled positioning, lounge or reclining chairs, and/or lift chairs;

(g) Enuresis (bed wetting) training equipment;

(h) Beds, other than hospital, bed boards/conversion kits, and bed lifters;

(i) Inflatable bed baths, sitz bath, paraffin bath units, and shampoo rings;

(j) Communication equipment and services including, but not limited to:

(i) Two-way radios;

(ii) Emergency response system services;

(iii) Devices intended to amplify or reduce background noise; and

(iv) Rental of related equipment or services;

(k) Computers, computer software, computer accessories (such as anti-glare shields, backup memory cards), and computer equipment other than specified in WAC 388-543-2300;

(l) Diathermy and diapulse machines;

(m) Vacuum cleaners, carpet cleaners/deodorizers, and/or pesticides/insecticides;

(n) Room fresheners/deodorizers;

(o) Cleaning brushes and supplies, except for ostomy-related cleaners/supplies;

(p) Identification bracelets;

(q) Car seats for children under five, except for positioning car seats that are prior authorized, as provided under WAC 388-543-1700(13);

(r) Generators;

(s) Instructional materials, such as pamphlets and videotapes; and

(t) Pouches, bags, baskets or other carrying containers for use with aids to mobility.

(6) Personal and comfort items, including but not limited to:

(a) Radio and television;

(b) Telephones, telephone arms, cellular phones, electronic beepers, and other telephone messaging services;

(d) Toothettes and toothbrushes, waterpics, or periodontal devices whether manual, battery-operated or electric;

(e) Bedside items such as carafes, bed trays, or over-the-bed tables;

(f) Eating/feeding utensils;

(g) Hot or cold temperature food and drink containers/holders;

(h) Emesis basins, enema bags, and diaper wipes;

(i) Impotence devices;

(j) Hot water bottles and cold/hot packs or pads;

(k) Diverter valves for bathtub;

(l) Bathroom items such as weight scales, towels, shower curtains, shower cap, shampoo, conditioner, soap, bath gel, moisturizer, astringent, toothpaste, deodorant, antiperspirant, mouthwash, shaving cream, powder;

(m) Cosmetics, including corrective formulations, skin bleaching, tanning, hair depilatories, and sun screen products;

(n) Insect repellents;

(o) Medicine cabinet and first aid items such as thermometers, bandaids, tongue depressors, medicine cups, cotton-tipped swabs, and cotton balls;

(p) Medication dispensers, such as med-collators and count-a-dose, except as obtained under the compliance packaging program. Refer to the pharmacy chapter 388-530 WAC.

(q) Page turners;

(r) Reachers;

(s) Massage equipment;

(t) Health club memberships;

(u) Clothing and accessories such as coats, hats, scarves, gloves (including wheelchair gloves), socks, and slippers; and

(v) Clothing protectors and other protective coverings against incontinence.

(7) Home improvements such as:

(a) Security systems, burglar alarms, call buttons, lights, light dimmers, motion detectors, and similar devices;

(b) Automatic door openers for the house or garage;

(d) Whirlpool systems such as jacuzzies, hot tubs, or spas;

(e) Swimming pools;

(f) Saunas;

(g) Wheelchair lifts or ramps for the home;

(h) Elevator systems, stair lifts; ceiling lifts and ceiling tracks;

(i) Electrical rewiring for any reason; and

(j) Any structural modifications to a client's house.

(8) Bilirubin lights, except as rentals, for at-home newborns with jaundice;

(9) Supplies and equipment used during a physician office visit, such as tongue depressors and surgical gloves;

(10) Supplies and equipment obtainable from, or provided free by community service organizations;

(11) Materials or services covered under manufacturers' warranties;

(12) Replacement batteries for other equipment, except as stated in WAC 388-543-1100(5);

(13) Procedures, prosthetics, or supplies related to gender dysphoria surgery;

(14) Temporary prostheses or prosthetic devices dispensed for cosmetic reasons;

(15) Shoe lifts less than one inch, arch supports, and nonorthopedic shoes;

(16) Hair pieces, wigs, or hair transplantations;

(17) Homemaker services and meals delivered to the home; and

(18) A client's utility bills, even if the operation or maintenance of a medical equipment purchased or rented by MAA for the client contributes to an increased utility bill.

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NEW SECTION

WAC 388-543-1400 General reimbursement--Medical equipment and related services. (1) A qualified provider who serves a client, who is not enrolled in a department-contracted managed care plan, will be reimbursed only when:

(a) The requirements of WAC 388-87-010 are met; and

(b) The item requested is not included with other reimbursement methodologies. Other reimbursement methodologies include, but are not limited to:

(i) Hospitals' diagnosis related group (DRG) reimbursement;

(ii) Nursing facilities' per diem rate;

(iii) Hospice providers' per diem reimbursement; or

(iv) Managed care plans' capitation rate.

(2) The maximum allowable fees will be set by MAA using available published information, such as:

(a) Medicare fee schedules;

(b) Manufacturers' catalogs;

(d) Wholesale prices.

(3) MAA may adopt policies, procedure codes and/or rates inconsistent with Medicare's, when MAA determines that it is in the best interest of it's clients.

(4) Maximum allowable fees will be updated for medical equipment and supplies and prosthetic devices no more than once per year. Rates may be updated for different categories of medical equipment and supplies and prosthetic/orthotic devices at different times during the year according to a schedule set by the MAA.

(5) A provider must not bill MAA for the rental or purchase of equipment supplied to the provider at no cost by suppliers/manufacturers.

(6) MAA's maximum payment for medical equipment and supplies will be the lesser of:

(a) Usual and customary charges; or

(b) Established rates, except as provided in subsection (7) of this section.

(7) If the service provided is covered by Medicare and Medicaid and is for a client, who is eligible for both Medicare and Medicaid, MAA will pay:

(a) The deductible and coinsurance up to Medicare's allowed amount; or

(b) For services that are not covered by Medicare but are covered, by MAA; if medically necessary.

(8) Medical goods and/or services that are provided to a client who is enrolled in a department-contracted managed care plan, but who failed to use the plan's participating provider, are not covered by MAA.

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NEW SECTION

WAC 388-543-1500 Purchasing medical equipment and related supplies, prosthetics and orthotics. Medical equipment and related supplies, prosthetics, and orthotics purchased by MAA for a client is the client's property.

(1) Reimbursement for covered medical equipment and related supplies, prosthetics, and orthotics includes:

(a) The manufacturer's warranty;

(b) Fitting and set-up;

(c) Any adjustments or modifications to the equipment required within three months of the date of purchase, except those occasioned by changes in the client's medical condition; and

(d) Instruction to the client or client's caregiver in the appropriate use of the equipment or device.

(2) Only new equipment that includes full manufacturer's and dealer's warranties must be provided to a MAA client.

(3) A dispensing provider must include a warranty for a period of one year after the date the rented equipment is deemed purchased as provided under WAC 388-543-1600(3).

(4) The dispensing provider's account will be charged for any costs incurred by MAA to have another provider repair equipment if:

(a) Medical equipment, which is deemed purchased by MAA under WAC 388-543-1600(3), requires repair during the applicable warranty period;

(b) The dispensing provider is unwilling or unable to make good on the warranty; and

(5) If rental equipment must be replaced during the warranty period, MAA will deduct from the dispensing provider's account fifty percent of the total amount MAA paid toward rental and eventual purchase of the first equipment.

(6) A purchase order for a prescribed item will be rescinded if the equipment was not delivered to the client, before the client:

(a) Dies; or

(b) Loses his or her medical eligibility.

(7) For rescinded purchase orders discussed in subsection (6) of this section, the provider may be paid an amount deemed appropriate by MAA to help defray the costs incurred for customized equipment, for which the provider may have already spent considerable resources, and which may not be easily resold. The provider must submit to MAA sufficient justification to support such claims.

(8) If a client becomes a managed care plan client before purchase of a prescribed medical equipment is completed, MAA will rescind the purchase order until the client has been evaluated by his or her primary care provider (PCP) in the managed care plan.

(a) The managed care PCP must write a new prescription if he or she determines the equipment or item is still medically necessary as defined in WAC 388-500-0005.

(b) The purchase or rental of the item is subject to the managed care plan's applicable reimbursement policies.

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NEW SECTION

WAC 388-543-1600 Medical equipment rentals by the medical assistance administration. (1) The reimbursement amount for rented medical equipment includes:

(a) Delivery to the client;

(b) Fitting, set-up and adjustments;

(d) Return pickup by the provider.

(2) A dispensing provider must ensure that durable medical equipment rented to a medical care client is:

(a) In good working order; and

(b) Comparable to equipment rented out by the provider to clients with similar medical equipment needs who are either private pay clients or have other third-party coverage.

(3) Rented equipment is deemed purchased after twelve months' rental, unless:

(a) Restricted as rental only; or

(b) Otherwise stated in MAA's published billing instructions.

(4) Medically necessary equipment, which may be rented, but will not be purchased for clients by MAA, includes, but is not limited to:

(a) Bilirubin lights for newborns at home with jaundice; and

(b) Electric breast pumps.

(5) The minimum rental period for medical equipment is one day.

(6) If a client becomes ineligible before the end of the month, the rental payment will cease the day, the client becomes ineligible.

(7) If a client becomes a managed care plan client, the rental payment will cease on the last day of the month preceding the month in which the client becomes enrolled in the managed care plan. The plan will determine the client's continuing need for the item or equipment and will be responsible for reimbursing the provider.

(8) Reimbursement for rental payment will cease on the date of the client's death. Monthly rentals will be prorated as appropriate.

(9) For a client who is eligible for both Medicaid and Medicare

(a) MAA will pay only the client's coinsurance and deductibles.

(b) Payment for rental or coinsurance and deductibles for equipment will be discontinued when:

(i) The reimbursement reaches Medicare's reimbursement cap for the equipment; or

(ii) Medicare deems the equipment purchased.

(10) The department does not obtain or pay for insurance coverage against liability, loss and/or damage to rental equipment that a provider supplies to a MAA client.

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NEW SECTION

WAC 388-543-1700 Items and services which require prior authorization. Items and services which require prior authorization include, but are not limited to:

(1) Wheelchairs, wheelchair accessories, wheelchair modifications, cushions, and repairs;

(2) Orthopedic shoes and selected orthotics;

(3) Augmentative communication devices;

(4) Osteogenic stimulator, noninvasive, if expedited authorization criteria are not met;

(5) Transcutaneous electrical nerve stimulators, if expedited authorization criteria are not met;

(6) Wheelchair-style shower/commode chairs;

(7) Hospital beds, if expedited authorization criteria are not met;

(8) Blood glucose monitors requiring special features;

(9) Air and gel cushions;

(10) Low air loss flotation system, if expedited authorization criteria are not met;

(11) Decubitus care mattress, including flotation or gel mattress, if expedited authorization criteria are not met;

(12) Decubitus care products and supplies;

(13) Positioning car seats for children under five years of age;

(14) Certain medical equipment and supplies listed as reimbursed "by report (BR)";

(15) Certain equipment rentals and certain prosthetic limbs, as specified in MAA's fee schedules and billing instructions;

(16) Equipment parts and labor charges for repairs or modifications and related services; and

(17) Other medical equipment not specifically listed in the department's billing instructions and is submitted as a miscellaneous procedure code.

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NEW SECTION

WAC 388-543-1800 Prior authorization--General policies. (1) The purchase of durable medical equipment and related supplies, prosthetic/orthotic devices, and other disposable/nonreusable medical supplies, and the rental of durable medical equipment will be authorized only if:

(a) A qualified provider, acting within his or her scope of practice, prescribes the item, and the prescription states the diagnosis, prognosis, and estimated length of need (weeks, months, or years);

(b) The items are medically necessary and sufficient objective evidence is submitted by the provider or client to establish medical necessity. Information used to establish medical necessity includes:

(i) A physiological description of the client's disease, injury, impairment, or other ailment, and any changes in the client's condition written by the prescribing physician, physical therapist, occupational therapist, or speech therapist;

(ii) Video and/or photograph(s) of the client demonstrating his/her impairments as well as the client's ability to use the requested equipment, when applicable.

(d) The provider/vendor obtains prior authorization, if required, as specified in WAC 388-543-1700 and 388-543-1800.

(2) The prescribing provider must provide patient-specific justification for the base equipment and each line item accessory or modification requested. General standards of care or industry standards for generalized equipment use is not acceptable justification.

(3) MAA will not consider prescriptions for items or services, which are older than three months at the time the initial request for authorization is received.

(4) Items requiring prior authorization listed, as "BR," in MAA's billing instructions will be authorized only if medical necessity is established and the provider gives the following information:

(a) A detailed description of the item or service to be provided;

(b) The procedure code that most closely describes the "by report" item and how the existing code description differs from the item to be provided;

(d) A copy of the manufacturer's invoice, price-list or catalog with product description for the item to be provided.

(5) Requests for authorization of equipment purchase or rental must include, but not be limited to, the following information:

(a) The manufacturer's name;

(b) The equipment model and serial number;

(d) Any modifications required, including the product or accessory number as shown in the manufacturer's catalog.

(6) Payment for repair and modification of client-owned equipment will be authorized only when the criteria in subsection (1) of this section are met. Requests for repairs must include the information listed in subsection (4) of this section.

(7) Reimbursement for purchase, rental or repair of medical equipment which duplicates equipment the client already owns or rents will not be authorized. If the client has similar or like-use equipment, the requesting provider must explain to MAA:

(a) Why the existing equipment no longer meets the client's medical needs; or

(b) Why it could not be repaired or modified to meet those medical needs.

(8) Medical equipment or services regarded by the medical profession as experimental in nature or as unacceptable treatment will not be authorized, unless the provider demonstrates through sufficient objective clinical evidence that the client exhibits particular circumstances rendering the requested service medically necessary.

(9) A request for an item will be denied, when a less costly, equally effective alternative is available that will meet the client's medical needs. MAA will inform the provider and/or the client of a less costly alternative from MAA's manufacturers' literature on file.

(10) When resubmitting a request for an item or service that has been denied, the provider must include new documentation relevant to the request.

(11) Rental equipment will be authorized for a specific period of time. The provider must request authorization from MAA for any extension of the rental period. Medical equipment is deemed purchased, after one year's rental, unless otherwise specified.

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NEW SECTION

WAC 388-543-1900 Wheelchairs. (1) MAA will consider a wheelchair purchase when the provider:

(a) Provides specific medical justification for the make and model of wheelchair requested;

(b) Defines the degree and extent of the client's impairment (such as stage of decubitus, severity of spasticity or flaccidity, degree of kyphosis or scoliosis); and

(c) Identifies and documents outcomes of less expensive alternatives (aids to mobility) that have been tried by the client.

(2) Wheelchair modifications will be considered when the provider indicates:

(a) The make/model and serial number of the wheelchair to be modified;

(b) The modification requested; and

(3) Wheelchair accessories or modifications, which are specifically identified by the manufacturer as a separate line item charge, in addition to the basic wheelchair, may be considered when the provider submits to MAA specific medical justification for each line item.

(4) Wheelchair repairs may be considered when the provider indicates the make, model and serial number of the wheelchair for which repairs are being requested.

(5) For a client living at home, MAA will consider rental or purchase of:

(a) A manual wheelchair if the client is nonambulatory or has limited mobility and requires a wheelchair to participate in normal daily activities.

(b) A standard wheelchair if the client's medical condition requires the client to have a wheelchair to participate in normal daily activities.

(i) Cannot self-propel a standard weight wheelchair; or

(ii) Requires custom modifications that cannot be provided on a standard weight wheelchair; and

(d) A high-strength lightweight wheelchair for a client:

(i) Whose medical condition is such that he or she cannot self-propel a lightweight or standard weight wheelchair; or

(ii) Requires custom modifications that cannot be provided on a standard weight or lightweight wheelchair.

(e) A heavy duty wheelchair for a client who requires a specifically manufactured wheelchair designed to:

(i) Support a person weighing up to three hundred pounds; or

(ii) Accommodate a seat width up to twenty-two inches wide (not to be confused with custom heavy duty wheelchairs).

(f) A custom heavy duty wheelchair for a client who requires a specifically manufactured wheelchair designed to:

(i) Support a person weighing over three hundred pounds; or

(ii) Accommodate a seat width over twenty-two inches wide.

(g) A rigid wheelchair for a client:

(i) With a medical condition that involves severe upper extremity weakness;

(ii) Who has a high level of activity; and

(iii) Who is unable to self-propel any of the above categories of wheelchair.

(h) A custom manufactured wheelchair for a client with a medical condition requiring wheelchair customization that cannot be obtained on any of the above categories of wheelchairs.

(i) A power-drive wheelchair only if the client's medical needs cannot be met by a less costly means of mobility. The prescribing physician must certify that the client can safely and effectively operate a power-drive wheelchair and that the client meets all of the following conditions:

(i) The client has severe abnormal upper extremity weakness and the extent of impairment is documented;

(ii) The client's medical condition negates his or her ability to self-propel any of the wheelchairs listed in the manual wheelchair category; and

(iii) A power-drive wheelchair will provide the client his/her only means of independent mobility; or

(iv) A power-drive wheelchair will enable a child to achieve age-appropriate independence and developmental milestones.

(j) A three or four-wheeled power-drive scooter/cart when the prescribing physician certifies:

(i) The client's condition is stable; and

(ii) The client is unlikely to require a standard power wheelchair within the next two years.

(6) The power wheelchair is considered to be the client's primary chair when the client has both a power wheelchair and a manual wheelchair.

(7) A second manual wheelchair, in addition to a power wheelchair, allowing a noninstitutionalized client to have dual wheelchairs, may be allowed when:

(a) The architecture of a client's home bathroom is such that power wheelchair access is not possible, and a manual wheelchair is needed to allow for safe and successful completion of bathroom activities and the maintenance of personal cleanliness;

(b) The architecture of the client's home is completely unsuitable for a power wheelchair, such as, narrow hallways, narrow doorways, steps at entryway, and insufficient turning radii;

(c) A client has a manual wheelchair providing sufficient independent mobility in the home but which is insufficient for independent mobility in the community, workplace or school environments; or

(d) A client has a power wheelchair but requires a manual wheelchair in addition to the power wheelchair because the client's community, workplace or educational activities cannot be met via transport of the power wheelchair. The manual wheelchair allows the client to be transported (with caregiver assistance) in a standard automobile or van. In these cases, two additional conditions must be met for the second wheelchair to be authorized:

(i) The activities necessitating the second wheelchair for the client must be located farther than one-fourth of a mile distance from the client's home; and

(ii) Cabulance, public buses or personal transit are neither available, practical, nor possible for financial or other reasons.

(8) Refer to WAC 388-543-1950 for MAA covered nursing facility wheelchair and associated accessories.

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NEW SECTION

WAC 388-543-2000 Reimbursement methodology for wheelchairs. (1) Reimbursement to a durable medical equipment provider for wheelchairs is based on the specific brand and model of wheelchair dispensed. Brands and/or models of wheelchairs are eligible for reimbursement based on:

(a) The client's medical needs;

(b) Product quality;

(d) Available alternatives.

(2) The maximum allowable reimbursement for basic standard wheelchairs is set at sixty-five percent of manufacturers' list prices in effect on January 31 of the base year.

(3) The maximum allowable reimbursement for add-on accessories and parts is set at eighty-four percent, and upcharge modifications to standard wheelchairs at eighty percent of manufacturers' list prices and/or invoice for the specific items in effect on January 31 of the base year.

(4) The maximum allowable reimbursement for all other manual wheelchairs and power wheelchairs is set at eighty-five percent of manufacturers' list prices in effect on January 31 of the base year.

(5) The wheelchair rental reimbursement is set based on average market rental rates for standard wheelchair models. The rental reimbursement is determined for the most common/average market rates for categories of manual and power-driven wheelchairs or from Medicare rates.

(6) The wheelchair fee schedule is evaluated and updated once a year. Wheelchair rate changes, in the aggregate, must not exceed the lesser of three percent annually or the applicable vendor rate increase, authorized by the legislature.

(7) The wheelchair rate changes will be implemented April 1 of the base year. Rate changes will be effective through the next rate determination cycle.

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NEW SECTION

WAC 388-543-2100 Hospital beds. (1) MAA will authorize hospital bed purchase or rental, if the following criteria are met:

(a) The client is bed-confined; and

(b) The client's medical need requires positioning that cannot be obtained in his/her regular bed, or that cannot be attained through less costly alternatives (such as use of bedside rails, a trapeze, pillows, bolsters, rolled up towels or blankets, or similar aids).

(2) The decision to rent or purchase a hospital bed will be based on the length of time the client needs the bed.

(a) If the need is for more than six months, MAA will consider a purchase.

(b) If the need is short term, MAA will initially authorize a maximum of two months rental, and allow extensions as medically necessary, upon request.

(d) If, after six months' rental, the client's medical need for the hospital bed still exists, the rental may be approved for up to an additional six months. The equipment will be considered purchased after a total of twelve months' rental.

(3) When the client has full-time caregivers, a manual hospital bed will be considered the primary option.

(4) A semi-electric hospital bed will be considered when the client meets all the criteria for a manual hospital bed, plus the following:

(a) The client requires the ability to change his or her position immediately; and

(b) The client is able to operate the controls independently.

(5) A full electric hospital bed will be considered only if the client meets all of the criteria for a manual hospital bed and the client needs to be in the trendelenburg position.

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NEW SECTION

WAC 388-543-2200 Bathroom/shower equipment. (1) A caster style shower commode chair will be considered as the primary option for clients.

(2) A wheelchair style shower commode chair will be considered only if the client:

(a) Is able to propel the equipment; or

(b) Has special positioning needs that cannot be met by a caster style chair.

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NEW SECTION

WAC 388-543-2300 Augmentative communication devices (ACD). (1) All requests for ACDs will be considered on a case-by-case basis.

(2) A provider must submit prior authorization requests for ACDs in writing to MAA with the following information:

(a) An assessment of the client's verbal capabilities by the prescribing physician or a licensed speech pathologist, who is well versed in the selection of ACDs;

(b) An assessment of the client's physical capabilities by the prescribing physician, licensed occupational therapist or physical therapist, if there is a physical disability, condition or impairment that requires the device or other equipment, such as wheelchairs, be specially adapted to accommodate the ACD;

(c) A detailed description of the client's therapeutic history including the nature, frequency, and duration of physical and occupational therapy and speech-language pathology;

(d) Documented trials of each ACD, that have been tried by the client, including less costly types or models, and the effectiveness of each device in promoting the client's ability to communicate with his or her health care providers and caregivers; and

(e) A plan of care indicating who will:

(i) Initially train the client in the use of the requested device;

(ii) Program the device;

(iii) Assess the efficacy of the equipment in meeting the client's stated needs; and

(iv) Monitor and re-evaluate the client on a periodic basis.

(3) Required assessments of the client's verbal and physical capabilities include, but are not limited to, the following:

(a) Hearing or visual loss;

(b) Muscular disorder;

(d) Significant surgeries related to the disability or need for the ACD;

(e) Missing limbs;

(f) Aphasia, apraxia, or dysarthria;

(g) The client's medical diagnosis and prognosis; and

(h) The client's cognitive abilities.

(4) The provider or client must prove that:

(a) The client has reliable and consistent motor response, which can be used to communicate with the help of an ACD;

(b) The client has the cognitive ability to effectively and independently utilize the equipment; and

(i) Communicate his or her medical condition, complaint, ailment or symptoms with his or her personal physician;

(ii) Communicate with his or her personal caregiver about both urgent medical needs and routine personal care needs;

(iii) Communicate with medical personnel engaged in providing emergency services, rehabilitative care, and other therapeutic treatment;

(iv) Improve expressive communications skills, vocabulary and understanding; and

(v) Attain specific speech therapy goals and objectives in the speech treatment or training plan.

(5) An ACD will be covered no more frequently than once every two years for a client who meets the criteria in subsection (4) of this section. A new or updated component, modification or replacement model will not be approved for a client whose ACD is less than two years old.

(6) Exceptions to subsection (5) of this section will be based strictly on a finding of unforeseeable and significant changes to the client's medical condition. The prescribing physician is responsible for justifying why the changes in the client's medical condition were unforeseeable.

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NEW SECTION

WAC 388-543-2400 Expedited authorization criteria for other durable medical equipment. Payment will be allowed by MAA, during a twelve-month period, for certain DME procedure codes through a process called expedited prior authorization process, if all specified criteria are satisfied. If all specified criteria are not met, or if the requested rental exceeds the limited rental period indicated, a normal prior authorization must be obtained. Compliance with the specific criteria must be documented in client files and presented to MAA upon request for post-pay review. Expedited criteria is defined for the following:

(1) Transcutaneous electrical nerve stimulators (TENS): An initial two-months rental for a TENS will be allowed if all the following expedited authorization criteria are met:

(a) The client has a condition that is causing chronic intractable pain;

(b) The client's pain level has been documented as six on a scale of one to ten, with one being low and ten being high;

(d) The client has had no surgery within the last three months;

(e) The client is on continual pain and/or anti-inflammatory medications;

(f) The client has had significant physical therapy of five or more visits within the last six months with no relief of pain or increased activity level; and

(g) The goal of the treatment is to decrease/discontinue medications and increase level of activity.

(2) Electric breast pumps: MAA will not purchase electric breast pumps. Rentals of electric breast pumps will be reimbursed, based on expedited authorization criteria if:

(a) A two-week rental for a client with engorged breasts;

(b) A three-week rental if the client is taking antibiotics for treatment of a breast infection; or

(i) The client's newborn is premature and is being kept in the hospital;

(ii) The mother has been discharged from the hospital; and

(iii) The mother is taking the breast milk to the hospital to be fed to the newborn.

(3) Continuous passive motion machine: Ten-day rental will be allowed upon hospital discharge, if the following criteria are met:

(a) Frozen joints;

(b) Intra-articular tibia plateau fracture;

(d) Total knee replacement.

(4) Osteogenesis stimulator: up to six months' rental will be allowed, if the following criteria are met:

(a) Nonunion of a bone fracture;

(b) At least six months have past since the date of injury or last procedure; and

(5) Sonic accelerated fracture system: Up to four months' rental will be allowed, if all of the following criteria are met:

(a) Client has a closed, fresh posteriorly displaced distal radius (Colles') fracture, or

(b) For closed or Grade 1 tibial diaphysis fractures in skeletally mature individuals when these fractures are being managed by closed reduction and case immobilization, and

(c) Documented evidence of reflecting efficacy of treatment every two months will be required for continuation of rental.

(6) Extremity pump: A two-months' rental will be allowed for treatment of severe edema.

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NEW SECTION

WAC 388-543-2500 Reimbursement methodology for other durable medical equipment. (1) For each "other durable medical equipment" category or procedure, which excludes wheelchairs and wheelchair accessories, the pricing cluster will include as many brands and/or models which MAA obtains pricing information. Pricing information is obtained through manufacturers' catalogs or commercial databases. However the number of brands and/or models included in a pricing cluster may be limited by MAA, if doing so is in the best interest of its clients. Consideration will be given to:

(a) A client's medical needs;

(b) Product quality;

(d) Available alternatives.

(2) The rates for other DME are established by taking the lesser of 79.5 percent of the manufacturers' list prices or 134.5 percent of the dealers cost in effect on July 31 of the base year. If the list price is available for an item the appropriate discount is applied. If acquisition cost is available the appropriate mark-up is applied. If both are available, the lesser of the appropriate discounted list price list or the appropriate marked-up acquisition cost is used. Otherwise it is whichever is available, the lesser prices calculated are rank ordered in descending order and the seventieth percentile is taken. Where fewer than six items are available, an average is calculated instead of the seventieth percentile.

(3) In cases where there is only one manufacturer for a covered item, and the manufacturer publishes only the dealers' acquisition cost for the item, MAA will be reimburse providers the published dealers' acquisition cost plus up to a 34.5 percent mark-up.

(4) Monthly rental rates are set by the MAA for other DME at one-tenth of the maximum allowable purchase price for the item.

(5) Daily rental rates for other durable medical equipment are set at one-three hundredth of the maximum allowable purchase price for the item. Rates for other durable medical equipment are evaluated and updated once a year.

(6) Rate changes will be implemented by MAA on October 1 of the base year and will be effective through the next rate determination cycle.

(7) Changes in other durable medical equipment rates, in the aggregate, will not exceed the lesser of three percent annually or the applicable vendor rate increase authorized by the legislature for other fee for service providers.

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NEW SECTION

WAC 388-543-2600 Prosthetics and orthotics. (1) Except for selected prosthetics and orthotics that do not require specialized skills to provide, prosthetics and orthotics will be reimbursed only to licensed prosthetic and orthotic providers accredited by the American Board for Certification in prosthetics and orthotics.

(2) Prosthetics dispensed for purely cosmetic reasons are not covered.

(3) A replacement prosthesis is covered only when purchase of a replacement prosthesis is a less costly alternative to repairing or modifying a client's current prosthesis.

(4) The client must take responsibility for routine maintenance of a prosthetic or orthotic. If the client does not have the physical or mental ability to perform the task, the client's caregiver must be responsible. MAA will consider authorizing extensive maintenance recommended by the manufacturer to be performed by an authorized dealer.

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NEW SECTION

WAC 388-543-2700 Reimbursement methodology for prosthetics and orthotics. (1) Prosthetics and orthotics reimbursement will be determined according to a set fee schedule. The maximum allowable fees will be aligned with Medicare's fee schedule as of January 1 of the base year.

(2) Reimbursement includes the cost of necessary molds of the prosthetic or orthotic.

(3) Prosthetics and orthotics placed during inpatient hospital stays are included in the hospital reimbursement rate.

(4) The maximum allowable fees for prosthetics and orthotics will be reviewed and updated once a year, independent of scheduled legislatively authorized vendor rate increases.

(5) The fee schedule changes for prosthetics and orthotics will be implemented July 1 of each year. Rates will be effective through the next rate determination cycle.

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NEW SECTION

WAC 388-543-2800 Reusable and disposable medical supplies and reimbursement. (1) Reusable and disposable medical supplies must be prescribed by a physician. The physician must state the pertinent diagnosis on the prescription form and clearly document it in the client's file.

(2) Medical supplies and nondurable medical equipment are categorized as follows:

(a) Syringes and needles;

(b) Blood monitoring supplies;

(d) Antiseptics and germicides;

(e) Bandages, dressings and tapes;

(f) Ostomy supplies;

(g) Urological supplies;

(h) Braces, belts, and supportive devices;

(i) Decubitus care products;

(j) Supplies associated with transcutaneous electrical nerve stimulators (TENS);

(k) Supplies associated with osteogenesis stimulators; and

(l) Miscellaneous supplies.

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NEW SECTION

WAC 388-543-2900 Reimbursement methodology for medical supplies and nondurable medical equipment. (1) Rates will be determined for each category using either the:

(a) Medicare fee schedule; or

(b) Manufacturers' catalogs; and

(2) The procedure codes and rates for the following categories will be aligned with Medicare's fee schedule:

(a) Bandages and dressings,

(b) Urological supplies (except diapers), and

The maximum allowable fees for these categories must be updated July 1 of each year, independent of scheduled legislatively authorized vendor rate increases.

(3) The maximum allowable fees for new products and/or supplies and equipment with Medicare's fee schedule are set by MAA using pricing information obtained through manufacturer's catalogs and or commercial databases. These rates are established by taking the lesser of eighty-five percent of manufacturers' list prices or one hundred twenty-five percent of dealers' acquisition cost for products in the pricing cluster, and averaging the cost.

(4) The maximum allowable fees for these other supplies and equipment in subsection (3) will be updated, when the legislature authorizes a vendor rate increase or decrease. Rate increases in the aggregate will not exceed legislatively authorized levels. Rate reductions mandated by the legislature may be applied to Medicare aligned codes.

(5) Reusable and disposable medical supplies required for a nursing facility client are paid through the nursing facility per diem rate. The following medical supplies may be paid separately for a client in a nursing facility:

(a) Medical supplies or services replacing all or parts of the function of a permanently impaired or malfunctioning internal body organ, such as colostomy (and other ostomy) bags and necessary supplies, and urinary retention catheters, tubes, and bags, excluding irrigation supplies;

(b) Supplies for intermittent catheterization programs, for the purpose of long term treatment of atonic bladder with a large capacity, and for short term management for temporary bladder atony; and

(6) Decubitus care products are included in the nursing facility per-diem rate and will not be reimbursed separately.

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NEW SECTION

WAC 388-543-3000 Medical equipment and supplies provided in physician's office. A durable medical equipment provider will be not paid for medical supplies used in conjunction with a physician office visit. The office physician will be paid for such supplies when appropriate.

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SHS-2476.1

AMENDATORY SECTION (Amending Order 2783, filed 3/31/89)

WAC 388-86-100 Durable medical equipment, prosthetic devices, and disposable/nonreuseable medical supplies. (1) ((~~The division of~~)) Medical assistance administration (MAA) shall purchase ((~~and/or rent~~)) medically necessary medical equipment, prosthetic devices, and other disposable/nonreuseable medical supplies when((:

~~(a) The division is the payor of last resort; and~~

~~(b) T~~)) the item requested is not included with other reimbursement methodologies, such as((~~, but not limited to, diagnosis related group (DRG) for hospital inpatients, or~~)) a nursing home's per diem reimbursement.

(2) ((~~The division of medical assistance~~)) MAA shall authorize payment for a requested item only when the item is medically necessary as defined under WAC 388-80-005(45) and is covered by the medical assistance program.

(3) ((~~The division of medical assistance~~)) MAA shall purchase ((~~and/or rent~~)) a wheelchair for a permanently disabled nursing ((~~home recipient~~)) facility client when the chair is for the exclusive full-time use of the recipient and is not included in the nursing home's per diem reimbursement.

(4) Medical equipment and supplies purchased or reissued by the ((~~division of medical assistance~~)) MAA become the property of the ((~~recipient~~)) nursing facility client for whom they are purchased/reissued.

(5) ((The division of medical assistance shall normally authorize the purchase and/or repair of only one wheelchair, manual or power-drive, per recipient. However, another wheelchair shall be provided and/or repaired when medically necessary.

~~(6) Durable medical equipment, prosthetic devices, and disposable/nonreuseable supplies that require approval by the division of medical assistance prior to delivery of service include:~~

~~(a) Prosthetic limbs;~~

~~(b) Orthopedic shoes;~~

~~(c) Osteogenic stimulator, noninvasive;~~

~~(d) Communication devices;~~

~~(e) Transcutaneous nerve stimulators;~~

~~(f) Wheeled shower chairs;~~

~~(g) Blood pressure kits;~~

~~(h) Blood glucose monitors;~~

~~(i) Air and gel cushions;~~

~~(j) Fluidized air flotation system;~~

~~(k) Decubitus care mattress, including flotation or gel mattress;~~

~~(l) Complete patient lift, except for sling or wall mount;~~

~~(m) Wheelchairs:~~

~~(i) Accessories;~~

~~(ii) Fitting fees; and~~

~~(iii) Freight charges.~~

~~(n) Hospital bed and replacement mattress;~~

~~(o) Replacement parts, repairs, and labor charges;~~

~~(p) Bath accessories, decubitus care products (nonformulary), and patient equipment not listed in the division of medical assistance "durable medical equipment and supplies" billing instructions; and~~

~~(q) All rentals.~~

~~(7) The division of medical assistance~~)) MAA shall not authorize the purchase of vehicle driving controls, a vehicle wheelchair lift conversion, or purchase or repair of a vehicle wheelchair lift, unless:

(a) Medical transportation provided under WAC 388-86-085 cannot meet the recipient's need for transportation to and from medically necessary covered services at a lower cost to the department; and

(b) Prior approval is obtained.

[Statutory Authority: RCW 74.08.090. 89-08-052 (Order 2783), � 388-86-100, filed 3/31/89; 86-03-047 (Order 2329), � 388-86-100, filed 1/15/86; 82-17-072 (Order 1868), � 388-86-100, filed 8/18/82; 81-16-033 (Order 1685), � 388-86-100, filed 7/29/81; 81-06-003 (Order 1610), � 388-86-100, filed 2/19/81; 78-10-077 (Order 1346), � 388-86-100, filed 9/27/78; 78-02-024 (Order 1265), � 388-86-100, filed 1/13/78; Order 1233, � 388-86-100, filed 8/31/77; Order 1019, � 388-86-100, filed 4/30/75; Order 938, � 388-86-100, filed 5/23/74; Order 499, � 388-86-100, filed 12/2/70; Order 480, � 388-86-100, filed 9/22/70; Order 463, � 388-86-100, filed 6/23/70; Order 419, � 388-86-100, filed 12/31/69; Order 385, � 388-86-100, filed 8/27/69; Order 264 (part), � 388-86-100, filed 11/24/67.]

AMENDATORY SECTION (Amending Order 3599, filed 7/28/93, effective 8/28/93)

WAC 388-86-200 Limits on scope of medical program services. (1) The medical assistance administration (MAA) shall pay only for equipment, supplies, and services that are listed as covered in MAA published issuances, including Washington Administrative Code (WAC), billing instructions, numbered memoranda, and bulletins, and when the items or services are:

(a) Within the scope of an eligible client's medical care program;

(b) Medically necessary;

(i) Consistent with a diagnosis; and

(ii) Reasonable in amount and duration of care, treatment, or service.

(d) Not listed under subsection (2) of this section; and

(e) Billed according to the conditions of payment under WAC 388-87-010.

(2) Unless required under EPSDT/healthy kids program; included as part of a managed care plan service package; included in a waivered program; or part of one of the Medicare programs for the qualified Medicare beneficiaries, the MAA shall specifically exclude from the scope of covered services:

(a) ((~~Nonmedical equipment, supplies, personal or comfort items and/or services, including, but not limited to:~~

~~(i) Air conditioners or air cleaner devices, dehumidifiers, other environmental control devices, heating pads;~~

~~(ii) Enuresis (bed wetting) training equipment;~~

~~(iii) Recliner and/or geri-chairs;~~

~~(iv) Exercise equipment;~~

~~(v) Whirlpool baths;~~

~~(vi) Telephones, radio, television;~~

~~(vii) Any services connected to the telephone, television, or radio;~~

~~(viii) Homemaker services;~~

~~(ix) Utility bills; or~~

~~(x)~~)) Meals delivered to the home.

(b) Services, procedures, treatment, devices, drugs, or application of associated services which the department or HCFA consider investigative or experimental on the date the services are provided;

(d) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness;

(e) Routine foot care that includes, but not limited to:

(i) Medically unnecessary treatment of mycotic disease;

(ii) Removal of warts, corns, or calluses;

(iii) Trimming of nails and other hygiene care; or

(iv) Treatment of asymptomatic flat feet.

(f) More costly services when less costly equally effective services as determined by the department are available;

(g) Procedures((,)) or treatment((~~, prosthetics, or supplies~~)) related to gender dysphoria surgery ((~~except when recommended after a multidisciplinary evaluation including but not limited to urology, endocrinology, and psychiatry~~));

(h) Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for sterilization reversals and donor ovum, sperm, or womb;

(i) Acupuncture, massage, or massage therapy;

(j) Orthoptic eye training therapy;

(k) Weight reduction and control services not provided in conjunction with a MAA medically approved program. This includes food supplements and educational products;

(l) Parts of the body, including organs tissues, bones, and blood;

(m) Blood and eye bank charges;

(n) Domiciliary or custodial care, excluding nursing facility care;

(o) ((~~Hair pieces, wigs, or hair transplantation;~~

~~(p)~~)) Biofeedback or other self-help care;

((~~(q)~~)) (p) Home births;

((~~(r)~~)) (q) Marital counseling or sex therapy; and

((~~(s)~~)) (r) Any service specifically excluded by statute.

(3) Clients shall be responsible for payment as described under WAC 388-87-010 for services not covered under the client's medical care program.

[Statutory Authority: RCW 74.08.090. 93-16-037 (Order 3599), � 388-86-200, filed 7/28/93, effective 8/28/93; 93-11-086 (Order 3536), � 388-86-200, filed 5/19/93, effective 6/19/93.]

REPEALER

The following section of the Washington Administrative Code is repealed:

WAC 388-86-110 X-ray services.

Legislature

Code Reviser

Register

� Washington State Code Reviser's Office