Original Notice.

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

Title of Rule: Repealing WAC 388-86-100 Durable medical equipment, prosthetics, orthotics and medical supplies and 388-87-110 Durable medical equipment -- Prosthetic devices; and new chapter 388-543 WAC, Durable medical equipment and related supplies, prosthetics, orthotics, medical supplies, and related services.

Purpose: The department is establishing a new chapter for durable medical equipment, chapter 388-543 WAC, so that all the rules relating to this subject will be contained in one WAC chapter. The new chapter codifies current policy and payment methodology, in compliance with Failor's Pharmacy v. DSHS lawsuit. The proposed rules have been written to comply with the Governor's Executive Order 97-02.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

Statute Being Implemented: Chapters 74.08, 74.09 RCW.

Summary: The proposed new WAC chapter consolidates all DME rules in one chapter for ease of use. The new chapter codifies current policy and payment methodology.

Reasons Supporting Proposal: To comply with the Governor's Executive Order 97-02. To comply with Failor's Pharmacy lawsuit judgment.

Name of Agency Personnel Responsible for Drafting: Ann Myers, DPS/RIP, P.O. Box 45530, Olympia, WA 98504, (360) 725-1345; Implementation and Enforcement: Sharon Morrison, DHSQS, P.O. Box 45506, Olympia, WA 98504, (360) 725-1671.

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

Rule is necessary because of state court decision, Failor's Pharmacy v. DSHS, 125 WN.2d 488, 886 P.2d 147 (1994).

Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule codifies current policy and payment methodology for durable medical equipment, prosthetics, and orthotics. The proposed rule implements a policy change that requires MAA to provide wheelchairs to clients in nursing facilities.

     The purpose is to clearly state current policy and payment methodology, and to codify the changed policy regarding wheelchairs for clients in nursing facilities.

     The anticipated effect is that providers and clients will have a clearer understanding of MAA policy, and that clients in nursing facilities will have greater access to wheelchairs.

Proposal Changes the Following Existing Rules: WAC 388-86-100 and 388-87-110 will be repealed and replaced with new chapter 388-543 WAC that incorporates a change in policy regarding wheelchairs for clients in nursing homes.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule and concludes that no new costs will be imposed on the small businesses affected by them.

RCW 34.05.328 applies to this rule adoption. The department has analyzed the proposed rule and concludes that it meets the definition of a "significant legislative rule." An analysis of the probable costs and probable benefits is available from the person listed above.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on August 8, 2000, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Fred Swenson by July 28, 2000, phone (360) 664-6097, TTY (360) 664-6178, e-mail swensfh@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by August 8, 2000.

Date of Intended Adoption: No sooner than August 9, 2000.

June 1, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

The following definitions and abbreviations and those found in WAC 388-500-0005 apply to this chapter. Defined words and phrases are bolded the first time they are used in the text.

     "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.      "Base year" means the year of the data source used in calculating prices.

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

     "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.

     "EPSDT/healthy kids" - see WAC 388-500-0005.

     "Expedited prior authorization (EPA)" means the process for obtaining authorization that must be used for selected durable medical equipment, and related supplies, prosthetics, orthotics, medical supplies and related services, in which providers use a set of numeric codes to indicate to MAA which acceptable indications/conditions/MAA-defined criteria are applicable to a particular request for DME authorization.

     "Fee-for-service (FFS)," means the general payment method MAA uses to reimburse for covered medical services provided to clients, except those services covered under MAA's managed care programs.

     "Health care financing administration common procedure coding system (HCPCS)" means a coding system established by the Health Care Financing Administration to define services and procedures.

     "House wheelchair" means a nursing facility wheelchair that is included in the nursing facility's per-patient-day rate under chapter 74.46 RCW.

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

     "Manual wheelchair" - see "wheelchair - manual."

     "Orthotic device" or "orthotic" 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.

     "Personal computer (PC)" means any of a variety of electronic devices that are capable of accepting data and instructions, executing the instructions to process the data, and presenting the results. A PC has a central processing unit (CPU), internal and external memory storage, and various input/output devices such as a keyboard, display screen, and printer. A computer system consists of hardware (the physical components of the system) and software (the programs used by the computer to carry out its operations).

     "Power-drive wheelchair" - see "wheelchair - power."

     "Prior authorization" means a process by which clients or providers must request and receive MAA approval for certain medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms of prior authorization. Also see WAC 388-501-0165.

     "Prosthetic device" or "prosthetic" 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.

     "Resource based relative value scale (RBRVS)" means a scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involve.

     "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, or gel mattress or overlay.

     "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 makes 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

     (c) Has a warranty period of at least one year.

     (2) Lightweight:

     (a) Composed of lightweight materials;

     (b) Capable of being modified;

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

     (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;

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

     (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.

[]

The federal government deems durable medical equipment (DME) 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 or required under the early and periodic screening, diagnosis and treatment (EPSDT)/healthy kids program. The department may reduce or eliminate coverage for optional services, consistent with legislative appropriations.

     (1) MAA covers only those DME and related supplies, prosthetics, orthotics, medical supplies and related services, repairs and labor charges, listed in MAA's published issuances, including Washington Administrative Code (WAC), billing instructions, and numbered memoranda.

     (2) MAA covers DME and related supplies, prosthetics, orthotics, medical supplies, related services, repairs and labor charges when all of the following apply. They must be:

     (a) Within the scope of an eligible client's medical care program (see chapter 388-529 WAC);

     (b) Within accepted medical or physical medicine community standards of practice;

     (c) Prior authorized as described in WAC 388-543-1600, 388-543-1800, and 388-543-1900;

     (d) Prescribed by a qualified provider, acting within the scope of the provider's practice. The prescription must state the specific item or service requested, diagnosis, prognosis, estimated length of need (weeks or months, not to exceed six months before being reevaluated), and quantity;

     (e) Billed to the department as the payor of last resort only. MAA does not pay first and then collect from Medicare;

     (f) Justified as medically necessary as determined by MAA. The provider or client must submit sufficient objective evidence to establish medical necessity. Information used to establish medical necessity includes, but is not limited to, the following:

     (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, licensed prosthetist and/or orthotist, physical therapist, occupational therapist, or speech therapist; or

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

     (3) MAA does not reimburse for DME and related supplies, prosthetics, orthotics, medical supplies, related services, and related repairs and labor charges under fee-for-service (FFS) when the client is any of the following:

     (a) An inpatient hospital client;

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

     (c) Terminally ill and receiving hospice care; or

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

     (4) MAA considers new technologies available through manufacturers to be noncovered unless MAA establishes coverage by assigning the technology a new procedure code and a reimbursement rate, or by assigning an existing procedure code. A manufacturer may request MAA to include new equipment/supplies in the billing instructions by sending a written request plus all of the following:

     (a) Manufacturer's literature;

     (b) Manufacturer's pricing;

     (c) Clinical research/case studies (including FDA approval, if required); and

     (d) Any additional information the manufacturer feels is important.

     (5) MAA bases the decision to purchase or rent DME for a client, or to pay for repairs to client-owned equipment, on the least costly and/or equally effective alternative.

     (6) MAA covers replacement batteries for purchased medically necessary DME equipment covered within this chapter.

     (7) MAA covers the following categories of medical equipment and supplies 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 DME;

     (c) Prosthetic/orthotic devices;

     (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.

     (8) MAA evaluates a BR item, procedure, or service for its medical appropriateness and reimbursement value on a case-by-case basis.

     (9) For a client in a nursing facility, MAA covers only the following when medically necessary. All other DME and supplies identified in MAA billing instructions are the responsibility of the nursing facility, in accordance with chapters 388-96 and 388-97 WAC. See also WAC 388-543-2900 (3) and (4). MAA covers:

     (a) The purchase and repair of an augmentative communication device (ACD), a wheelchair, or specialty bed; and

     (b) The rental of a speciality bed.

[]

(1) MAA requires a provider who supplies DME and related supplies, prosthetics, orthotics, medical supplies and related services to an MAA client to meet all of the following. The provider must:

     (a) Have the proper business license;

     (b) Have appropriately trained qualified staff; and

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

     (2) MAA may reimburse qualified providers for DME and related supplies, prosthetics, orthotics, medical supplies, repairs, and related services on a fee-for-service (FFS) basis as follows:

     (a) DME providers for DME and related repair services;

     (b) Medical equipment dealers, pharmacies, and home health agencies under their medical vendor provider number for medical supplies, subject to the limitations in this section;

     (c) Licensed prosthetics and orthotics providers who are licensed by the Washington state department of health in prosthetics and orthotics. This does not apply to medical equipment dealers and pharmacies that do not require licensure to provide selected prosthetics and orthotics; and

     (d) Physicians who provide medical equipment and supplies in the physician's office. MAA may pay separately for medical supplies, subject to the provisions in MAA's resource based relative value scale (RBRVS) fee schedule.

     (3) MAA terminates from Medicaid participation any provider who violates program regulations and policies, as described in WAC 388-502-0020.

[]

MAA pays only for medical equipment, supplies, and services that are listed as covered and meet MAA's definition of DME. DME means equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use in the client's place of residence. All requests for noncovered equipment, and related supplies prosthetics, orthotics, medical supplies and related services will be reviewed based on WAC 388-501-0165(8). Case-by-case exceptions will only be considered based on WAC 388-501-0160. MAA specifically excludes services and equipment in this chapter from fee-for-service (FFS) scope of coverage. This exclusion does not apply if the services and equipment are required under the 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. Excluded services and equipment include, but are not limited to:

     (1) Services, procedures, treatment, devices, drugs, or the application of associated services that the department of 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) Any service specifically excluded by statute;

     (3) More costly services or equipment when MAA determines that less costly, equally effective services or equipment are available;

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

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

     (6) Hairpieces or wigs;

     (7) Material or services covered under manufacturers' warranties;

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

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

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

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

     (12) Home improvements, including but not limited to the following:

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

     (b) Saunas;    

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

     (d) Swimming pools;

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

     (f) Structural modifications of any kind to a client's house, including but not limited to, the following:

     (i) Electrical rewiring for any reason;

     (ii) Elevator systems, elevators, ceiling lifts and ceiling tracks, stair lifts; and

     (iii) Wheelchair lifts or ramps for the home; or

     (iv) Installation of bathtubs or shower stall.

     (13) Nonmedical equipment, supplies, and related services, including but not limited to, the following:

     (a) Back-packs, pouches, bags, baskets, or other carrying containers for use with aids to mobility;

     (b) Bed wetting (Enuresis) prevention training equipment;

     (c) Beds other than hospital, bed boards/conversion kits, and blanket lifters (e.g., for feet);

     (d) Car seats for children under five, except for positioning car seats that are prior authorized. Refer to WAC 388-543-1700(13) for car seats;

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

     (f) Diathermy machines used to produce heat by high frequency current, ultrasonic waves, or microwave radiation;

     (g) Electronic communication equipment, installation services, or service rates including but not limited to the following:

     (i) Devices intended for amplifying voices (e.g., microphones);

     (ii) Interactive communications computer programs used between patients and healthcare providers (e.g., hospitals, physicians), for self care home monitoring, or emergency response systems and services;

     (iii) Two-way radios; and

     (iv) Rental of related equipment or services;

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

     (i) Ergonomic equipment;

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

     (k) Generators;

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

     (m) Personal computers including laptops, computer software, printers, computer accessories (such as anti-glare shields, backup memory cards), and computer equipment other than specified in WAC 388-543-2300;

     (n) Racing strollers/wheelchairs and recreational equipment;

     (o) Room fresheners/deodorizers;

     (p) Sitz bath, bidet or hygiene systems, paraffin bath units, and shampoo rings;

     (q) Timers or electronic devices to turn things on or off;

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

     (s) Wheeled reclining chairs, lounge and/or lift chairs (e.g., geri-chair, posture guard, or lazy boy).

     (14) Personal and comfort items, including but not limited to the following:

     (a) Bathroom items, such as antiperspirant, astringent, bath gel, conditioner, deodorant, moisturizer, mouthwash, powder, sanitary napkins (e.g., Kotex), shampoo, shaving cream, shower cap, shower curtains, soap, toothpaste, towels, and weight scales;

     (b) Bedding items, such as bed pads, blankets, mattress covers/bags, pillows, pillow cases/covers and sheets;

     (c) Bedside items, such as bed trays, carafes, and over-the-bed tables;

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

     (e) Clothing protectors and other protective cloth furniture coverings as protection against incontinence;

     (f) Cosmetics, including corrective formulations, hair depilatories, and products for skin bleaching, sun screens, and tanning;

     (g) Diverter valves for bathtub;

     (h) Eating/feeding utensils;

     (i) Emesis basins, enema bags, peri-wash, and diaper wipes;

     (j) Health club memberships;

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

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

     (m) Impotence devices;

     (n) Insect repellants;

     (o) Massage equipment;

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

     (q) Medicine cabinet and first aid items, such as adhesive bandages (e.g., Band-Aids, Curads), cotton balls, cotton-tipped swabs, medicine cups, thermometers, and tongue depressors;

     (r) Page turners;

     (s) Radio and television;

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

     (u) Toothettes and toothbrushes, waterpics, and peridontal devices whether manual, battery-operated, or electric.

     (15) Certain wheelchair features and options are not considered by MAA to be medically necessary or essential for wheelchair use. This includes, but is not limited to, the following:

     (a) Attendant controls (remote control devices);

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

     (c) Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps for cars);

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

     (e) Lighting systems;

     (f) Speed conversion kits; and

     (g) Tie-down restraints.

[]

(1) MAA reimburses a qualified provider who serves a client who is not enrolled in a department-contracted managed care plan only when all of the following apply:

     (a) The provider meets all of the conditions in WAC 388-502-0100; and

     (b) MAA does not include the item/service for which the provider is requesting reimbursement in other reimbursement rate methodologies. Other methodologies include, but are not limited to, the following:

     (i) Hospice providers' per diem reimbursement;

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

     (iii) Managed care plans' capitation rate; and

     (iv) Nursing facilities' per diem rate.

     (2) MAA sets maximum allowable fees for medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services using available published information, such as:

     (a) Commercial databases for price comparisons;

     (b) Manufacturers' catalogs;

     (c) Medicare fee schedules; and

     (d) Wholesale prices.

     (3) MAA may adopt policies, procedure codes, and/or rates that are inconsistent with those set by Medicare if MAA determines that such actions are in the best interest of its clients.

     (4) MAA updates the maximum allowable fees for medical equipment and supplies and prosthetic/orthotic devices no more than once per year, unless otherwise directed by the legislature. MAA may update the rates for different categories of medical equipment and prosthetic/orthotic devices at different times during the year.

     (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 is the lesser of either of the following:

     (a) Providers' usual and customary charges; or

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

     (7) If a client is eligible for both Medicare and Medicaid, the following apply:

     (a) MAA requires a provider to accept Medicare assignment before any Medicaid reimbursement;

     (b) If the service provided is covered by Medicare and Medicaid, MAA pays:

     (i) The deductible and coinsurance up to Medicare's allowed amount or MAA's allowed amount, whichever is less; or

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

     (8) MAA may pay for medical services rendered to a client only when MAA is the payor of last resort.

     (9) MAA does not cover medical equipment and/or services provided to a client who is enrolled in a MAA-contracted managed care plan, but did not use the plan's participating provider.

     (10) See WAC 388-543-2100, 388-543-2500, 388-543-2700, and 388-543-2900 for other reimbursement methodologies.

[]

(1) Durable medical equipment (DME) and related supplies, prosthetics, and orthotics purchased by MAA for a client is the client's property.

     (2) MAA's reimbursement for covered DME and related supplies, prosthetics, and orthotics includes all of the following:

     (a) Any adjustments or modifications to the equipment that are required within three months of the date of delivery. This does not apply to adjustments required because of changes in the client's medical condition;

     (b) Fitting and set-up; and

     (c) Instruction to the client or client's caregiver in the appropriate use of the equipment, device, and/or supplies.

     (3) MAA requires a provider to furnish to MAA clients only new equipment that includes full manufacturer and dealer warranties.

     (4) MAA requires a dispensing provider to include a warranty on equipment for one year after the date MAA considers rented equipment to be purchased, as provided under WAC 388-543-1700(3).

     (5) MAA charges the dispensing provider for any costs it incurs to have another provider repair equipment if all of the following apply:

     (a) Any DME that MAA considers purchased according to WAC 388-543-1700 requires repair during the applicable warranty period;

     (b) The dispensing provider is unwilling or unable to fulfill the warranty; and

     (c) The client still needs the equipment.

     (6) MAA charges the dispensing provider fifty percent of the total amount MAA paid toward rental and eventual purchase of the first equipment if the rental equipment must be replaced during the warranty period. All of the following must apply:

     (a) Any medical equipment that MAA considers purchased according to WAC 388-543-1700 requires replacement during the applicable warranty period;

     (b) The dispensing provider is unwilling or unable to fulfill the warranty; and

     (c) The client still needs the equipment.

     (7) Purchase orders:

     (a) MAA rescinds any purchase order for a prescribed item if the equipment was not delivered to the client before the client:

     (i) Dies;

     (ii) Loses medical eligibility;

     (iii) Becomes covered by a hospice agency; or

     (iv) Becomes covered by an MAA managed care plan. Refer to subsection (7)(c) of this section.

     (b) A provider may incur extra costs for customized equipment that may not be easily resold. In these cases, for purchase orders rescinded per (a) of this subsection, MAA may pay the provider an amount it considers appropriate to help defray these extra costs. MAA requires the provider to submit justification sufficient to support such a claim.

     (c) A client may become a managed care plan client before MAA completes the purchase of prescribed medical equipment. If this occurs:

     (i) MAA rescinds the purchase order until the managed care primary care provider (PCP) evaluates the client; then

     (ii) MAA requires the PCP to write a new prescription if the PCP determines the equipment is still medically necessary as defined in WAC 388-500-0005; then

     (iii) The managed care plan's applicable reimbursement policies apply to the purchase or rental of the equipment.

[]

MAA requires providers to obtain prior authorization for certain items and services. This includes, but is not limited to, the following:

     (1) Augmentative communication devices (ACDs);

     (2) Certain by report (BR) DME and supplies as specified in MAA's published issuances, including billing instructions and numbered memoranda;

     (3) Blood glucose monitors requiring special features;

     (4) Certain equipment rentals and certain prosthetic limbs, as specified in MAA's published issuances, including billing instructions and numbered memoranda;

     (5) Decubitus care products and supplies;

     (6) Decubitus care mattresses, including flotation or gel mattress, if the provider fails to meet the criteria in WAC 388-543-1900;

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

     (8) Hospital beds, if the provider fails to meet the requirements in WAC 388-543-1900;

     (9) Low air loss flotation system, if the provider fails to meet the requirements in WAC 388-543-1900;

     (10) Orthopedic shoes and selected orthotics;

     (11) Osteogenic stimulator, noninvasive, if the provider fails to meet the requirements in WAC 388-543-1900;

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

     (13) Transcutaneous electrical nerve stimulators, if the provider fails to meet the requirements in WAC 388-543-1900;

     (14) Wheelchairs, wheelchair accessories, wheelchair modifications, air, foam, and gel cushions, and repairs;

     (15) Wheelchair-style shower/commode chairs; and

     (16) Other DME not specifically listed in MAA's published issuances, including billing instructions and numbered memoranda, and submitted as a miscellaneous procedure code.

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(1) MAA's reimbursement amount for rented durable medical equipment (DME) includes all of the following:

     (a) Delivery to the client;

     (b) Fitting, set-up, and adjustments;

     (c) Maintenance, repair and/or replacement of the equipment; and

     (d) Return pickup by the provider.

     (2) MAA requires a dispensing provider to ensure the DME rented to a MAA client is both of the following:

     (a) In good working order; and

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

     (3) MAA considers rented equipment to be purchased after twelve months' rental unless one of the following apply:

     (a) The equipment is restricted as rental only; or

     (b) Other MAA published issuances state otherwise.

     (4) MAA rents, but does not purchase, certain medically necessary equipment for clients. This includes, but is not limited to, the following:

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

     (b) Electric breast pumps.

     (5) MAA's minimum rental period for covered DME is one day.

     (6) If a client becomes ineligible before the end of the month, MAA stops paying for any rented equipment effective the date the client becomes ineligible.

     (7) If a fee-for-service (FFS) client becomes a managed care plan client, both of the following apply:

     (a) MAA stops paying for any rented equipment on the last day of the month preceding the month in which the client becomes enrolled in the managed care plan; and

     (b) The plan determines the client's continuing need for the equipment and is responsible for reimbursing the provider.

     (8) MAA stops paying for any rented equipment effective the date of a client's death. MAA prorates monthly rentals as appropriate.

     (9) For a client who is eligible for both Medicaid and Medicare, MAA pays only the client's coinsurance and deductibles. MAA discontinues paying client's coinsurance and deductibles for rental equipment when either of the following applies:

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

     (b) Medicare considers the equipment purchased.

     (10) MAA 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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(1) A provider/vendor may obtain expedited prior authorization (EPA) from MAA according to WAC 388-543-1900.

     (2) For prior authorization requests, MAA requires the prescribing provider to furnish patient-specific justification for base equipment and each requested line item accessory or modification as identified by the manufacturer as a separate charge. MAA does not accept general standards of care or industry standards for generalized equipment as justification.

     (3) When MAA receives an initial request for prior authorization, the prescription(s) for those items or services cannot be older than three months from the date MAA receives the request.

     (4) MAA authorizes BR items that require prior authorization and are listed in MAA's published issuances, including billing instructions and numbered memoranda, only if medical necessity is established and the provider furnishes all of the following information to MAA:

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

     (b) The cost or charge for the item;

     (c) A copy of the manufacturer's invoice, price-list or catalog with the product description for the item being provided; and

     (d) A detailed explanation of how the requested item differs from an already existing code description.

     (5) MAA requires certain information from providers in order to prior authorize the purchase or rental of equipment. This information includes, but is not limited to, the following:

     (a) The manufacturer's name;

     (b) The equipment model and serial number;

     (c) A detailed description of the item; and

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

     (6) MAA prior authorizes payment for repair and modification of client-owned equipment only when the criteria in subsection (1) of this section are met. Requests for repairs must include the information listed in subsection (5) of this section.

     (7) MAA does not reimburse for purchase, rental, or repair of medical equipment that duplicates equipment the client already owns or rents. If the requesting provider makes such a request, MAA requires the provider to submit for prior authorization and explain the following:

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

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

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

     (9) A provider may resubmit a request for prior authorization for an item or service that MAA has denied. MAA requires the provider to include new documentation that is relevant to the request.

     (10) MAA authorizes rental equipment for a specific period of time. The provider must request authorization from MAA for any extension of the rental period.

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(1) The expedited prior authorization process (EPA) is designed to eliminate the need for written and telephonic requests for prior authorization for selected DME procedure codes. MAA allows payment during a continuous twelve-month period for this process.

     (2) MAA requires a provider to create an authorization number for EPA for selected DME procedure codes. The process and criteria used to create the authorization number is explained in MAA published DME-related billing instructions. The authorization number must be used when the provider bills MAA.

     (3) The written or telephonic request for prior authorization process must be used when a situation does not meet the criteria for a selected DME code or a requested rental exceeds the limited rental period indicated.

     (4) Upon request, a provider must provide documentation to MAA showing how the client's condition met the criteria for EPA in subsection (2) of this section.

     (5) MAA may recoup any payment made to a provider under this section if the provider did not follow the expedited authorization process and criteria. Refer to WAC 388-502-0100.

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(1) MAA purchases a wheelchair for a client when MAA determines that a wheelchair is medically necessary for more than six months.

     (2) The following apply when MAA determines that a wheelchair is medically necessary for six months or less:

     (a) If the client lives at home, MAA rents a wheelchair for the client; or

     (b) If the client lives in a nursing facility, the nursing facility must provide a house wheelchair as part of the per diem rate paid by AASA.

     (3) MAA considers rental or purchase of a manual wheelchair if the client is nonambulatory or has limited mobility and requires a wheelchair to participate in normal daily activities. MAA determines the type of manual wheelchair based on the following:

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

     (b) A standard lightweight wheelchair if the client's medical condition is such that the client:

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

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

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

     (i) Whose medical condition is such that the client 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.

     (d) 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).

     (e) 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.

     (f) 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.

     (g) 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.

     (4) MAA considers 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:

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

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

     (c) A power-drive wheelchair will provide the client the only means of independent mobility; or

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

     (e) The following additional information is required for a three or four-wheeled power-drive scooter/cart:

     (i) The prescribing physician certifies that the client's condition is stable; and

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

     (5) MAA considers the power-drive wheelchair to be the client's primary chair when the client has both a power-drive wheelchair and a manual wheelchair.

     (6) In order to consider purchasing a wheelchair, MAA requires the provider to submit the following information from the prescribing physician or occupational therapist:

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

     (b) Define 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) Documented outcomes of less expensive alternatives (aids to mobility) that have been tried by the client.

     (7) In addition to the basic wheelchair, MAA may consider wheelchair accessories or modifications that are specifically identified by the manufacturer as separate line item charges. The provider must submit specific medical justification for each line item, with the modification request.

     (8) MAA considers wheelchair modifications to a medically necessary wheelchair when the provider submits all of the following with the modification request:

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

     (b) The modification requested; and

     (c) Specific information regarding the client's medical condition that necessitates the modification.

     (9) MAA may consider wheelchair repairs to a medically necessary wheelchair; the provider must submit to MAA the make, model, and serial number of the wheelchair for which the repairs are requested.

     (10) MAA may cover two wheelchairs, a manual wheelchair and a power-drive wheelchair, for a noninstitutionalized client in certain situations. One of the following must apply:

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

     (b) The architecture of the client's home bathroom is such that power-drive wheelchair access is not possible, and the client needs a manual wheelchair to safely and successfully complete bathroom activities and maintain personal cleanliness;

     (c) The client has a power-drive wheelchair, but also requires a manual wheelchair because the power-drive wheelchair cannot be transported to meet the client's community, workplace, or educational activities; the manual wheelchair would allow the caregiver to transport the client in a standard automobile or van. In these cases, MAA requires the client's situation to meet both of the following conditions:

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

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

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(1) MAA reimburses a DME provider for purchased wheelchairs for a home or nursing facility client based on the specific brand and model of wheelchair dispensed. MAA decides which brands and/or models of wheelchairs are eligible for reimbursement based on all of the following:

     (a) The client's medical needs;

     (b) Product quality;

     (c) Cost; and

     (d) Available alternatives.

     (2) For HCPCS codes for wheelchair rentals and wheelchair accessories (e.g., cushions and backs), MAA uses the Medicare fees that are current on April 1 of each year.

     (3) For state-assigned procedure codes, including those listed as BR, for wheelchairs and wheelchair accessories, MAA's maximum allowable reimbursement is based on a percentage of the manufacturer's list price in effect on January 31 of the base year, or the invoice for the specific item. This applies to the following:

     (a) For basic standard wheelchairs, sixty-five percent;

     (b) For add-on accessories and parts, eighty-four percent;

     (c) For upcharge modifications and cushions, eighty percent;

     (d) For all other manual wheelchairs, eighty percent; and

     (e) For all other power-drive wheelchairs, eighty-five percent .

     (4) MAA determines rental reimbursement for categories of manual and power-driven wheelchairs based on average market rental rates or Medicare rates.

     (5) MAA evaluates and updates the wheelchair fee schedule once per year.

     (6) MAA implements wheelchair rate changes on April 1 of the base year, and the rates are effective until the next rate change.

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(1) MAA considers all requests on a case-by-case basis for augmentative communication devices (ACDs) for the purpose of relaying medical information.

     (2) MAA requires a provider to submit a prior authorization request for ACDs. The request must be in writing and contain all of the following information:

     (a) A detailed description of the client's therapeutic history;

     (b) An assessment by a licensed speech pathologist of the client's verbal capabilities. The pathologist must be knowledgeable about selecting ACDs that meet the client's needs;

     (c) If the client has a physical disability, condition, or impairment that requires equipment, such as a wheelchair, or a device to be specially adapted to accommodate an ACD, an assessment by the prescribing physician, licensed occupational therapist or physical therapist; and

     (d) Documented trials of each ACD that the client has tried. This includes less costly types/models, and the effectiveness of each device in promoting the client's ability to communicate with health care providers and caregivers.

     (3) MAA requires the provider to show or the client to demonstrate all of the following:

     (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

     (c) With the ADC, the client will be able to do all of the following:

     (i) Communicate with the personal physician about the medical condition, complaint, ailment, or symptoms;

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

     (iii) Communicate with medical personnel who provide emergency services, rehabilitative care, and other therapeutic treatment;

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

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

     (4) MAA covers ACDs only once every two years for a client who meets the criteria in subsection (3) of this section. MAA does not approve a new or updated component, modification, or replacement model for a client whose ACD is less than two years old. MAA may make exceptions to the criteria in subsection (3) of this section 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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(1) MAA considers a caster-style shower commode chair as the primary option for clients.

     (2) MAA considers a wheelchair-style shower commode chair only if the client meets both of the following:

     (a) Is able to propel the equipment; and

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

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(1) MAA bases the decision to rent or purchase a hospital bed on the length of time the client needs the bed, as follows:

     (a) MAA initially authorizes a maximum of two months rental for a short-term need. Upon request, MAA may allow extensions as medically necessary;

     (b) MAA determines rental on a month-to-month basis if a client's prognosis is poor;

     (c) MAA considers a purchase if the need is for more than six months;

     (d) If the client continues to have a medical need for a hospital bed after six months, MAA may approve rental for up to an additional six months. MAA considers the equipment to be purchased after a total of twelve months' rental.

     (2) MAA considers a manual hospital bed the primary option when the client has full-time caregivers.

     (3) MAA considers a full electric hospital bed only if the client meets all of the following criteria:

     (a) The client's medical need requires the client to be positioned in a way that is not possible in a regular bed;

     (b) The position cannot be attained through less costly alternatives (e.g., the use of bedside rails, a trapeze, pillows, bolsters, rolled up towels or blankets);

     (c) The client's medical condition requires immediate position changes;

     (d) The client is able to operate the controls independently; and

     (e) The client needs to be in the Trendelenburg position.

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(1) For the purposes of this section, MAA uses the following terms:

     (a) "Other durable medical equipment (other DME)" means all durable medical equipment, excluding wheelchairs and related items.

     (b) "Pricing cluster" means a group of discounted manufacturers' list prices and/or dealer's costs for brands/models of other DME that MAA uses to calculate the reimbursement rate for a procedure code that does not have a fee established by Medicare. MAA uses the discounted manufacturer list price for a brand/model unless that price is not available.

     (2) MAA establishes reimbursement rates for purchased other DME.

     (a) For HCPCS procedure codes that have a Medicare rate established for a new purchase, MAA uses the rate that is in effect on January first of the year in which MAA sets the reimbursement.

     (b) For all other procedure codes, MAA uses a pricing cluster to establish the rate.

     (3) Establishing a pricing cluster and reimbursement rates.

     (a) In order to make up a pricing cluster for a procedure code, MAA determines which brands/models of other DME its clients most frequently use. MAA obtains prices for these brands/models from manufacturer catalogs or commercial databases. MAA may change or otherwise limit the number of brands/models included in the pricing cluster, based on the following:

     (i) Client medical needs;

     (ii) Product quality;

     (iii) Introduction of new brands/models;

     (iv) A manufacturer discontinuing or substituting a brand/model; and/or

     (v) Cost.

     (b) If a manufacturer list price is not available for any of the brands/models used in the pricing cluster, MAA calculates the reimbursement rate at the manufacturer's published cost to providers plus a thirty-five percent mark-up.

     (c) For each brand used in the pricing cluster, MAA discounts the manufacturer's list price by twenty percent.

     (i) If six or more brands/models are used in the pricing cluster, MAA calculates the reimbursement rate at the seventieth percentile of the pricing cluster.

     (ii) If five brands/models are used in the pricing cluster, MAA establishes the reimbursement rate at the fourth highest discounted list price, as described in (b) of this subsection.

     (iii) If four brands/models are used in the pricing cluster, MAA establishes the reimbursement rate at the third highest discounted list price, as described in (b) of this subsection.

     (iv) If three brands/models are used in the pricing cluster, MAA establishes the reimbursement rate at the third highest discounted list price, as described in (b) of this subsection.

     (v) If two or fewer brands/models are used in the pricing cluster, MAA establishes the reimbursement rate at the highest discounted list price, as described in (b) of this subsection.

     (4) Rental reimbursement rates for other DME.

     (a) MAA sets monthly rental rates at one-tenth of the purchase reimbursement rate as it would be calculated as described in subsections (2) and (3) of this section.

     (b) MAA sets daily rental rates at one-three hundredth of the purchase reimbursement rate as it would be calculated as described in subsections (2) and (3) of this section.

     (5) MAA annually evaluates and updates reimbursement rates for other DME.

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(1) MAA reimburses for prosthetics and orthotics to licensed prosthetic and orthotic providers only. This does not apply to selected prosthetics and orthotics that do not require specialized skills to provide.

     (2) MAA does not cover prosthetics dispensed for purely cosmetic reasons.

     (3) MAA covers a replacement prosthesis only when the purchase of a replacement prosthesis is less costly than repairing or modifying a client's current prosthesis.

     (4) MAA requires the client to 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, MAA requires the client's caregiver to be responsible. MAA authorizes extensive maintenance that the manufacturer recommends be performed by an authorized dealer.

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(1) MAA determines reimbursement for prosthetics and orthotics according to a set fee schedule. MAA considers Medicare's current fee schedule when determining maximum allowable fees. For BR codes, MAA reimburses eighty-five percent of the agreed upon fee.

     (2) MAA's reimbursement for a prosthetic or orthotic includes the cost of any necessary molds.

     (3) MAA's hospital reimbursement rate includes any prosthetics and/or orthotics required for surgery and/or placed during the hospital stay.

     (4) MAA evaluates and updates the maximum allowable fees for prosthetics and orthotics once per year, independent of scheduled legislatively authorized vendor rate increases.

     (5) MAA implements fee schedule changes for prosthetics and orthotics July 1 of each year. Rates remain effective until the next rate change.

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(1) MAA requires that a physician prescribe reusable and disposable medical supplies. The prescription must state the specific item or service requested, diagnosis, prognosis, estimated length of need (weeks or months, not to exceed six months before being re-evaluated), and quantity.

     (2) MAA categorizes medical supplies and non-DME (MSE) as follows:

     (a) Antiseptics and germicides;

     (b) Bandages, dressings, and tapes;

     (c) Blood monitoring supplies;

     (d) Braces, belts, and supportive devices;

     (e) Decubitus care products;

     (f) Ostomy supplies;

     (g) Pregnancy-related testing kits and nursing equipment;

     (h) Supplies associated with osteogenesis stimulators;

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

     (j) Syringes and needles;

     (k) Urological supplies; and

     (l) Miscellaneous supplies.

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(1) MAA determines rates for each category of medical supplies and non-DME (MSE) using either the:

     (a) Medicare fee schedule; or

     (b) Manufacturers' catalogs and commercial databases for price comparisons.

     (2) MAA evaluates and updates the maximum allowable fees for MSE as follows:

     (a) For HCPCS MSE codes, MAA considers the current Medicare fee schedule;

     (b) For all MSE with state-assigned procedure codes, when the legislature mandates a vendor rate increase or decrease.

     (c) MAA sets the maximum allowable fees for new MSE using one of the following:

     (i) Medicare's fee schedule; or

     (ii) For those items without a Medicare fee, commercial databases to obtain all brands to make up MAA's pricing cluster. MAA establishes the fee for products in the pricing cluster by using the lesser of either:

     (A) Eighty-five percent of the average manufacturer's list price; or

     (B) One hundred twenty-five percent of the average dealer cost.

     (d) All the brands for which MAA obtains pricing information make up MAA's pricing cluster. However, MAA may limit the number of brands included in the pricing cluster if doing so is in the best interests of its clients. MAA considers all of the following:

     (i) A client's medical needs;

     (ii) Product quality;

     (iii) Cost; and

     (iv) Available alternatives.

     (4) MAA's nursing facility per diem rate includes any reusable and disposable medical supplies that may be required for a nursing facility client. MAA may reimburse the following medical supplies separately for a client in a nursing facility:

     (a) Medical supplies or services that replace all or parts of the function of a permanently impaired or malfunctioning internal body organ. This includes, but is not limited to the following:

     (i) Colostomy and other ostomy bags and necessary supplies; and

     (ii) Urinary retention catheters, tubes, and bags, excluding irrigation supplies;

     (b) Supplies for intermittent catheterization programs, for the following purposes:

     (i) Long term treatment of atonic bladder with a large capacity; and

     (ii) Short term management for temporary bladder atony; and

     (c) Surgical dressings required as a result of a surgical procedure, for up to six weeks after surgery.

     (5) MAA considers decubitus care products to be included in the nursing facility per diem rate and does not reimburse for these separately.

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Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 388-543-3000
DME and supplies provided in physician's office.

MAA does not pay a DME provider for medical supplies used in conjunction with a physician office visit. MAA pays the office physician for these supplies, as stated in the RBRVS, when it is appropriate.

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© Washington State Code Reviser's Office