SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: November 16, 2000.
Purpose: The department has consolidated rules regarding maternity related services and rules on HIV/AIDS related services. The proposed rules reflect long-standing department policy, are more readable, and comply with the Governor's Executive Order 97-02 on regulatory reform. WAC 388-86-017 had been proposed for repeal but will instead be moved and renumbered at the request of other divisions of DSHS. New WAC 388-533-0350 Maternity case management, 388-539-0300 Case management for persons living with HIV/AIDS, and 388-539-0350 HIV/AIDS Case management reimbursement.
Statutory Authority for Adoption: RCW 74.08.090.
Other Authority: RCW 74.09.755, 74.09.800, 42 U.S.C. Section 1915(g).
Adopted under notice filed as WSR 00-17-082 on August 14, 2000.
Changes Other than Editing from Proposed to Adopted Version: The department had proposed to repeal WAC 388-86-017 but has temporarily retained this section at the request of other divisions of DSHS that have not separately promulgated case management regulations.
Changes to WAC 388-533-0350:
(2) To receive MCM services t
The client must be eligible for
MAA's pregnancy and birth coverage under WAC 388-462-015 and meet
both of the following to be eligible for MCM services. In
addition, t The client must:
Is Be pregnant ; and (b) Is at high risk for a poor birth
outcome as documented by a completed MCM intake (see MAA's MCM
billing instructions) .; or
(b) Have experienced a poor birth outcome and have the MCM intake completed as described in subsections (3)(b) or (3)(c) of this section.
(3) The MCM intake that initiates MCM services must be
during the client's pregnancy.:
(a) During the eligible client's pregnancy; (b) By the day
of discharge from the hospital of the eligible birth mother; or
(c) By the day of discharge from the hospital of the eligible
MCM services must begin prior to the child's
birth and MCM intake is considered the beginning of MCM services.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 3, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.
November 16, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit2758.7
MAA provides HIV/AIDS case management to assist persons infected with HIV to: Live as independently as possible; maintain and improve health; reduce behaviors that put the client and others at risk; and gain access to needed medical, social, and educational services.
(1) To be eligible for MAA reimbursed HIV/AIDS case management services, the person must:
(a) Have a current medical diagnosis of HIV or AIDS;
(b) Be eligible for Title XIX (Medicaid) coverage under either the categorically needy program (CNP) or the medically needy program (MNP); and
(i) Assistance to obtain and effectively use necessary medical, social, and educational services; or
(ii) Ninety days of continued monitoring as provided in WAC 388-539-0350(2).
(2) MAA has an interagency agreement with the Washington state department of health (DOH) to administer the HIV/AIDS case management program for MAA's Title XIX (Medicaid) clients.
(3) HIV/AIDS case management agencies who serve MAA's clients must be approved to perform these services by HIV client services, DOH.
(4) HIV/AIDS case management providers must:
(a) Notify HIV positive persons of their statewide choice of available HIV/AIDS case management providers and document that notification in the client's record. This notification requirement does not obligate HIV/AIDS case management providers to accept all clients who request their services.
(b) Have a current client-signed authorization to release/obtain information form. The provider must have a valid authorization on file for the months that case management services are billed to MAA (see RCW 70.02.030). The fee referenced in RCW 70.02.030 is included in MAA's reimbursement to providers. MAA's clients may not be charged for services or documents related to covered services.
(c) Maintain sufficient contact to ensure the effectiveness of ongoing services per subsection (5) of this section. MAA requires a minimum of one contact per month between the HIV/AIDS case manager and the client. However, contact frequency must be sufficient to ensure implementation and ongoing maintenance of the individual service plan (ISP).
(5) HIV/AIDS case management providers must document services as follows:
(a) Providers must initiate a comprehensive assessment within two working days of the client's referral to HIV/AIDS case management services. Providers must complete the assessment before billing for ongoing case management services. If the assessment does not meet these requirements, the provider must document the reason(s) for failure to do so. The assessment must include the following elements as reported by the client:
(i) Demographic information (e.g., age, gender, education, family composition, housing.);
(ii) Physical status, the identity of the client's primary care provider, and current information on the client's medications/treatments;
(iii) HIV diagnosis (both the documented diagnosis at the time of assessment and historical diagnosis information);
(iv) Psychological/social/cognitive functioning and mental health history;
(v) Ability to perform daily activities;
(vi) Financial and employment status;
(vii) Medical benefits and insurance coverage;
(viii) Informal support systems (e.g., family, friends and spiritual support);
(ix) Legal status, durable power of attorney, and any self-reported criminal history; and
(x) Self-reported behaviors which could lead to HIV transmission or re-infection (e.g., drug/alcohol use).
(b) Providers must develop, monitor, and revise the client's individual service plan (ISP). The ISP identifies and documents the client's unmet needs and the resources needed to assist in meeting the client's needs. The case manager and the client must develop the ISP within two days of the comprehensive assessment or the provider must document the reason this is not possible. An ISP must be:
(i) Signed by the client, documenting that the client is voluntarily requesting and receiving MAA reimbursed HIV/AIDS case management services; and
(ii) Reviewed monthly by the case manager through in-person or telephone contact with the client. Both the review and any changes must be noted by the case manager:
(A) In the case record narrative; or
(B) By entering notations in, initialing and dating the ISP.
(c) Maintained ongoing narrative records - These records must document case management services provided in each month for which the provider bills MAA. Records must:
(i) Be entered in chronological order and signed by the case manager;
(ii) Document the reason for the case manager's interaction with the client; and
(iii) Describe the plans in place or to be developed to meet unmet client needs.
(1) MAA reimburses HIV/AIDS case management providers for the following three services:
(a) Comprehensive assessment - The assessment must cover the areas outlined in WAC 388-539-0300(1) and (5).
(i) MAA reimburses only one comprehensive assessment unless the client's situation changes as follows:
(A) There is a fifty percent change in need from the initial assessment; or
(B) The client transfers to a new case management provider.
(ii) MAA reimburses for a comprehensive assessment in addition to a monthly charge for case management (either full-month or partial-month) if the assessment is completed during a month the client is Medicaid eligible and the ongoing case management has been provided.
(b) HIV/AIDS case management, full-month - Providers may request the full-month reimbursement for any month in which the criteria in WAC 388-539-0300 have been met and the case manager has an individual service plan (ISP) in place for twenty or more days in that month. MAA reimburses only one full-month case management fee per client in any one month.
(c) HIV/AIDS case management, partial-month - Providers may request the partial-month reimbursement for any month in which the criteria in WAC 388-539-0300 have been met and the case manager has an ISP in place for fewer than twenty days in that month. Using the partial-month reimbursement, MAA may reimburse two different case management providers for services to a client who changes from one provider to a new provider during that month.
(2) MAA limits reimbursement to HIV/AIDS case managers when a client becomes stabilized and no longer needs an ISP with active service elements. MAA limits reimbursement for monitoring to ninety days past the time the last active service element of the ISP is completed. Case Management providers who are monitoring a stabilized client must meet all of the following criteria in order to bill MAA for up to ninety days of monitoring:
(a) Document the client's history of recurring need;
(b) Assess the client for possible future instability; and
(c) Provide monthly monitoring contacts.
(3) MAA reinstates reimbursement for ongoing case management if a client shifts from monitoring status to active case management status due to documented need(s). Providers must meet the requirements in WAC 388-539-0300 when a client is reinstated to active case management.
(1) The medical assistance administration's (MAA) maternity case management (MCM) services are designed to assist pregnant or parenting client(s) obtain needed medical, social, educational, and other services.
(2) To receive MCM services the client must be eligible for MAA's pregnancy and birth coverage under WAC 388-462-015. In addition, the client must:
(a) Be pregnant and at high risk for a poor birth outcome as documented by a completed MCM intake (see MAA's MCM billing instructions); or
(b) Have experienced a poor birth outcome and have the MCM intake completed as described in subsection (3)(b) or (c) of this section.
(3) The MCM intake that initiates MCM services must be completed:
(a) During the eligible client's pregnancy;
(b) By the day of discharge from the hospital of the eligible birth mother; or
(c) By the day of discharge from the hospital of the eligible newborn child.
(4) MAA considers a client to be at high risk for a poor birth outcome if the client meets any of the following conditions. The client:
(a) Is age seventeen years or younger;
(b) Uses alcohol or other drug(s);
(c) Is in an environment where alcohol or drugs pose a risk; or
(d) Demonstrates an inability to obtain needed resources or services and is experiencing any three of the following:
(i) Has an inadequate physical or emotional support system or has an uninvolved domestic partner;
(ii) Has two or more children at home, ages four and/or younger;
(iii) Has an eighth grade or less education;
(iv) Has a physical disability;
(v) Has medical factors that MAA recognizes as related to poor pregnancy or birth outcomes (e.g., diabetes; see MAA's specific program billing instructions);
(vi) Has refugee status;
(vii) Is mentally impaired (e.g., mental depression is interfering with daily functioning);
(viii) Is homeless;
(ix) Is in a household that has current or recent incidents of violence (i.e., physical or sexual abuse);
(x) Is limited English proficient;
(xi) Is eighteen or nineteen years of age; or
(xii) Entered into prenatal care after twenty-eight weeks gestation.
(5) MAA covers MCM services provided to the eligible woman for up to sixty days postpartum, and provided to the eligible infant until age one.
(6) MAA covers MCM services provided to high-risk clients in addition to the services described in WAC 388-533-0300, Enhanced benefits for pregnant women. A client may receive services under WAC 388-533-0300 and services under this section at the same time or at different times.
(7) MAA reimburses only those providers who have been specifically approved by and contracted with MAA to furnish MCM services. For approval, providers must contact:
The Medical Assistance Administration
Division of Program Support, Family Services Section
POB 45530, Olympia, Washington 98504-5530.
(8) MCM providers must document the qualifying high-risk factors in the client's MCM case file. There must be an active MCM service plan demonstrating client need for MCM services, and the provider must periodically review and update the plan. MCM providers must not bill MAA for MCM services once the client is able to obtain needed services or systems without MCM assistance.
(9) MAA's reimbursement for MCM services may vary, depending on the client's specific risk factors and need(s).
(10) MAA publishes MCM program billing instructions that contain specific process requirements for the MCM program.