WSR 00-23-052

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed November 13, 2000, 3:25 p.m. ]

Date of Adoption: November 13, 2000.

Purpose: The department has established a new chapter to incorporate and consolidate rules regarding maternity related services. The rules being adopted reflect long-standing operational policy, are more readable and they comply with the Governor's Executive Order 97-02 on regulatory reform. The rules have been developed with the assistance of the regulated parties. New rules being adopted are WAC 388-533-0400 Maternity care and newborn delivery and 388-533-0600 Births in birthing centers. WAC 388-533-0500 was proposed but has not been adopted with this order so that the department may pursue a pilot project for home birth settings.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-059 and 388-87-079; and amending WAC 388-86-200.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: RCW 74.09.760 through 74.09.800.

Adopted under notice filed as WSR 00-14-064 on July 5, 2000.

Changes Other than Editing from Proposed to Adopted Version: The department has filed a supplemental CR-102 for WAC 388-533-0500 so that planned home births can be better monitored as part of a pilot project. WAC 388-533-0500 is to be adopted at a later date.

WAC 388-533-0400 Maternity care and newborn delivery, 388-533-0600 Births in birthing centers, and 388-86-200 Limits on scope of medical program services.

WAC 388-533-0400 (1)(d), global fee means the fee MAA pays for total obstetrical care. Total obstetrical care includes all bundled antepartum care, delivery services and postpartum care.

WAC 388-533-0400 (15)(b), planned home birth settings, as described in WAC 388-533-0500 for providers who are participating in MAA's home birth pilot project.

WAC 388-533-0600(1), MAA covers births in birthing centers for its clients when: (a) The client meets the same eligibility criteria as those in WAC 388-533-0500(1); and (b) Tthe client and the maternity care provide choose an MAA approved birthing center. and the client:

(a) Is eligible for CN or MN scope of care (see WAC 388-533-0400(2));

(b) Has an MAA approved medical provider who has accepted responsibility for the birthing center birth as provided in this section;

(c) Is expected to deliver the child vaginally and without complication (i.e., with a low risk of adverse birth outcome); and

(d) Passes MAA's risk-screening criteria. MAA provides these risk-screening criteria to qualified medical services providers.

WAC 388-86-200 (2)(q), Marital counseling or sex therapy; and

(r) Any service specifically excluded by statute.; and

(s) Home births, except when provided as an approved service under MAA's planned home birth pilot project.

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

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

Number of Sections Adopted on the Agency's Own Initiative: New 2, Amended 1, Repealed 2.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 2, Amended 1, Repealed 2.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 2, Amended 1, Repealed 2. Effective Date of Rule: Thirty-one days after filing.

November 13, 2000

Edith M. Rice, Chief

Office of Legal Affairs

2700.11
NEW SECTION
WAC 388-533-0400
Maternity care and newborn delivery.

(1) 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.

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

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

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

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

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

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

(2) MAA covers full scope maternity care and newborn delivery services to its clients who qualify for categorically needy (CN) or medically needy (MN) scope of care (see WAC 388-462-0015 for client eligibility).

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

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

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

(b) Any other program not listed.

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

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

(b) Have signed core provider agreements with MAA;

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

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

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

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

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

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

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

(a) Through a global obstetrical fee; or

(b) Through separate fees in any combination:

(i) First trimester antepartum care;

(ii) Second trimester antepartum care;

(iii) Third trimester antepartum care;

(iv) Delivery services (intrapartum care); and

(v) Postpartum care.

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

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

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

(b) Under separate trimester care fees.

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

(a) An initial and any subsequent patient history;

(b) All physical examinations;

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

(d) Recording fetal heart tones;

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

(f) Maternity counseling.

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

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

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

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

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

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

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

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

(b) Has a diagnosis of multiple births.

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

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

(a) Inpatient hospital; or

(b) Birthing centers.

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

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

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

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

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

(a) The admissions history and physical examination;

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

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

(d) Cesarean delivery of the newborn.

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

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

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

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

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

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

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

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

(a) High-risk vaginal delivery;

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

(c) High-risk cesarean section delivery.

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

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

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

[]


NEW SECTION
WAC 388-533-0600
Births in birthing centers.

(1) MAA covers births in birthing centers for its clients when the client and the maternity care provider choose an MAA-approved birthing center and the client:

(a) Is eligible for CN or MN scope of care (see WAC 388-533-400(2));

(b) Has a MAA-approved medical provider who has accepted responsibility for the birthing center birth as provided in this section;

(c) Is expected to deliver the child vaginally and without complication (i.e., with a low risk of adverse birth outcome); and

(d) Passes MAA's risk screening criteria. MAA provides these risk-screening criteria to qualified medical services providers.

(2) Each participating birthing center must:

(a) Be licensed as a childbirth center by the department of health (DOH) under chapter 246-349 WAC;

(b) Have a valid core provider agreement with MAA;

(c) Be specifically approved by MAA to provide birthing center services; and

(d) Maintain standards of care required by DOH for licensure.

(3) MAA suspends or terminates the core provider agreement of a birthing center if it fails to maintain DOH standards cited in subsection (2) of this section.

(4) MAA approves only the following provider types to provide MAA covered births in birthing centers:

(a) Physicians licensed under chapters 18.57 or 18.71 RCW;

(b) Nurse midwives licensed under chapter 18.79 RCW; and

(c) Midwives licensed under chapter 18.50 RCW.

(5) Each provider using a birthing center must:

(a) Obtain from the client a signed consent form in advance of the birthing center birth;

(b) Follow MAA's risk screening criteria and consult with and/or refer the client or newborn to a physician or hospital when medically appropriate;

(c) Have current, written, and appropriate plans for consultation, emergency transfer and transport of a client and/or newborn to a hospital;

(d) Make appropriate referral of the newborn for screening and medically necessary follow-up care; and

(e) Inform parents of the benefits of a newborn screening test and offer to send the newborn's blood sample to the department of health for testing.

[]

2662.1
REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-86-059 Licensed midwife services.
WAC 388-87-079 Payment--Licensed midwives.
2771.3
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;

(c) Within accepted medical, dental, or psychiatric practice standards and are:

(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;

(c) Physical examinations or routine checkups;

(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, 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) ((Home births;

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

(((s))) (r) Any service specifically excluded by statute; and

(s) Home births, except when provided as an approved service under MAA's planned home birth pilot project.

(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.]


NEW SECTION

The following section of the Washington Administrative Code, as amended, is recodified as follows:

Old WAC Number New WAC Number
388-86-200 388-501-0300

Washington State Code Reviser's Office