Original Notice.

     Preproposal statement of inquiry was filed as WSR 00-19-030.

     Title of Rule: Amending WAC 388-550-2501 Acute physical medicine and rehabilitation (acute PM&R) program -- General, 388-550-2511 Acute PM&R definitions, 388-550-2521 Client eligibility requirements for acute PM&R services, 388-550-2531 Requirements for becoming an MAA Level A or B acute PM&R provider, 388-550-2541 Quality of care for acute PM&R clients through audits and reviews, 388-550-2551 How MAA determines client placement in Level A or B acute PM&R, 388-550-2561 MAA's requirements for authorizing acute PM&R services and 388-550-3381 How MAA pays acute PM&R facilities for Level A services; and repealing WAC 388-550-3401 How MAA pays acute PM&R facilities for Level B services.

     Purpose: Incorporates contract language into rule, updates policy, and removes references to acute PM&R Level A and Level B services.

     Other Identifying Information: MAA uses the federal Medicare rehabilitation guidelines as a guide for the acute PM&R program.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, and 42 C.F.R. 482.56.

     Statute Being Implemented: RCW 74.08.090, 74.09.520, and 42 C.F.R. 482.56.

     Summary: The department is incorporating contract language into rule, removing Level B services from the program and repealing WAC 388-550-3401. The program will continue to provide acute PM&R services while removing references to Level A and B services.

     Reasons Supporting Proposal: The rules replace the contract since contracts are not used to negotiate rates or services provided, and are not required to keep the acute PM&R program operational. Level B services started in 1999 as part of a budget proviso at the request of a nursing facility. This facility is no longer qualified to provide Level B services as a result of dropping its CARF (the Rehabilitation Accreditation Commission) certification, which is required by MAA's acute PM&R program. Since there are currently no nursing facility requests to provide Level B services, and since hospitals are requesting Level A services for clients and not Level B services, the department is eliminating Level B services from the program.

     Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45533, Olympia, WA 98504, (360) 725-1342; Implementation and Enforcement: Larry Linn, P.O. Box 45510, Olympia, WA 98504, (360) 725-1856.

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

     Rule is not necessitated by federal law, federal or state court decision.

     Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule incorporates acute PM&R provider contract language into rule, removes references to Level A and Level B acute PM&R services, and updates and clarifies current program policy.

     Since contracts are not used to negotiate rates or services provided, and are not required to keep the acute PM&R program operational, the purpose of the rule is to replace the contract. See Purpose, Summary, and Reasons Supporting Proposal above.

     The anticipated effects are the acute PM&R contract is no longer needed, and the program will be more cost effective with the elimination of Level B services in nursing facilities and hospitals. The rules clarify that only MAA-authorized hospital facilities may provide acute PM&R program services to eligible clients.

     Proposal Changes the Following Existing Rules: The department is repealing WAC 388-550-3401 How MAA pays acute PM&R facilities for Level B services. Level B services are no longer part of the acute PM&R program.

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

     RCW 34.05.328 applies to this rule adoption. The proposed rule does meet the definition of a "significant legislative rule" and the department has prepared an evaluation of probable costs and benefits, which may be obtained by contacting the person at the address listed below.

     Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on January 22, 2003, at 10:00 a.m.

     Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by January 17, 2003, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

     Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., January 22, 2003.

     Date of Intended Adoption: Not sooner than January 23, 2003.

November 27, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (1) ((A multidisciplinary)) An interdisciplinary team coordinates individualized ((client)) acute PM&R services at an MAA-approved rehabilitation facility to achieve the following for ((the)) a client:

     (a) Improved health and welfare; and

     (b) Maximum physical, social, psychological and educational or vocational potential.

     (2) MAA determines ((the)) and authorizes a length of stay based on ((individual cases and)):

     (a) The client's acute PM&R needs; and

     (b) Community standards of care for acute PM&R services.

     (3) When MAA's authorized acute period of rehabilitation ends, the provider transfers the client to a more appropriate level of care. Therapies may continue to help the client achieve maximum potential through other MAA programs such as:

     (a) Home health services (((see subchapter II of chapter 388-551 WAC)));

     (b) Nursing facilities (((see chapter 388-97 WAC); or

     (c) Outpatient hospital services (see chapter 388-550 WAC)));

     (c) Outpatient physical, occupational, and speech therapies; or

     (d) Neurodevelopmental centers.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, § 388-550-2501, filed 8/18/99, effective 9/18/99.]

     "Accredit" (or "Accreditation") ((is)) means a term used by nationally recognized health organizations, such as CARF, to state a facility meets community standards of medical care.

     "Acute" means an intense medical episode, not longer than ((two)) three months.

     "Acute physical medicine and rehabilitation (acute PM&R)" means a comprehensive inpatient rehabilitative program coordinated by ((a multidisciplinary)) an interdisciplinary team at an MAA-approved rehabilitation facility. The program provides twenty-four-hour specialized nursing services and an intense level of therapy for ((a diagnostic category)) specific medical conditions for which the client shows significant potential for functional improvement.

     "Administrative day" means a day of a hospital stay in which an acute inpatient level of care is no longer necessary, and noninpatient hospital placement is appropriate.

     "Administrative day rate" means the statewide Medicaid average daily nursing facility rate as determined by the department.

     "CARF((.))" is the official name for 'The Rehabilitation Accreditation Commission' of Tucson, Arizona. CARF is a national private agency that develops and maintains current, "field-driven" (community) standards through surveys and accreditations of rehabilitation facilities.

     (("Level A services" mean hospital-based acute rehabilitation services for medically stable clients with conditions that require complex nursing, medical and therapy needs as listed in WAC 388-550-2551(2). Such conditions include, but are not limited to, traumatic brain injuries, spinal cord injuries, and complicated bilateral amputations.

     "Level B services" mean hospital- or nursing facility-based acute rehabilitation services for medically stable clients with new or exacerbated multiple sclerosis, mild head injuries, spinal cord injuries following the removal of the thoracic lumbar sacral orthosis (TLSO), and other medical conditions that require less complex nursing, medical and therapy needs as listed in WAC 388-550-2551(3).))

     "Rehabilitation Accreditation Commission, The" - See "CARF."

     "Survey" or "review" means an inspection conducted by a federal, state, or private agency to evaluate and monitor a facility's compliance with acute PM&R program requirements.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, § 388-550-2511, filed 8/18/99, effective 9/18/99.]

     (4) If a client is enrolled in an MAA Healthy Options managed care plan at the time of acute care admission, that plan pays for and coordinates acute PM&R services as appropriate)) (1) Only a client who is eligible for one of the following programs may receive acute PM&R services, subject to the restrictions and limitations in this section and WAC 388-550-2501, 388-550-2511, 388-550-2531, 388-550-2541, 388-550-2551, 388-550-2561, 388-550-3381, and other published rules:

     (a) Categorically needy program (CNP);

     (b) CNP - Children's health insurance program (CNP-CHIP);

     (c) Limited casualty program - Medically needy program (LCP-MNP);

     (d) CNP - Emergency medical only;

     (e) LCP-MNP - Emergency medical only;

     (f) General assistance unemployable (GAU - No out-of-state care);

     (g) Alcoholism and drug addiction treatment and support act (ADATSA); and

     (h) Medically indigent program (MIP) - Emergency hospital-based and emergency transportation services only when:

     (i) The client is transferred directly from an acute hospital stay; and

     (ii) The client's acute PM&R needs are directly related to the emergency medical condition that qualified the client for MIP.

     (2) If a client is enrolled in an MAA Healthy Options managed care plan at the time of acute care admission, that plan pays for and coordinates acute PM&R services as appropriate.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, § 388-550-2521, filed 8/18/99, effective 9/18/99.]

     (5) MAA will revoke a conditional contract approval if the facility does not obtain full CARF accreditation within twelve months of the conditional approval date by MAA)) (1) Only an in-state or border area hospital may apply to become a medical assistance administration (MAA)-approved acute PM&R facility. To apply, MAA requires the hospital provider to submit a letter of request to:

     Acute PM&R Program Manager

     Division of Medical Management - Medical Operations

     Medical Assistance Administration

     PO Box 45506

     Olympia, WA 98504-5506

     (2) A hospital that applies to become an acute PM&R facility must provide MAA with documentation that confirms the facility is all of the following:

     (a) A Medicare-certified hospital;

     (b) Accredited by the Joint Commission on Accreditation of Hospital Organizations (JCAHO);

     (c) Licensed by the department of health (DOH) as an acute care hospital as defined under WAC 246-310-010;

     (d) CARF accredited as a comprehensive integrated inpatient rehabilitation program or as a pediatric family centered rehabilitation program, unless subsection (3) of this section applies;

     (e) Contracted under MAA's selective contracting program, if in a selective contracting area, unless exempted from the requirements by MAA; and

     (f) Operating per the standards set by DOH (excluding the certified rehabilitation registered nurse (CRRN) requirement) in either:

     (i) WAC 246-976-830, Level I trauma rehabilitation designation; or

     (ii) WAC 246-976-840, Level II trauma rehabilitation designation.

     (3) A hospital not yet accredited by CARF:

     (a) May apply for or be awarded a twelve-month conditional written approval by MAA if the facility:

     (i) Provides MAA with documentation that it has started the process of obtaining full CARF accreditation; and

     (ii) Is actively operating under CARF standards.

     (b) Is required to obtain full CARF accreditation within twelve months of MAA's conditional approval date. If this requirement is not met, MAA sends a letter of notification to revoke the conditional approval.

     (4) A hospital qualifies as an MAA-approved acute PM&R facility when:

     (a) The facility meets all the applicable requirements in this section;

     (b) MAA's clinical staff has conducted a facility site visit; and

     (c) MAA provides written notification that the facility qualifies to be reimbursed for providing acute PM&R services to eligible medical assistance clients.

     (5) MAA-approved acute PM&R facilities must meet the general requirements in chapter 388-502 WAC, Administration of medical programs--Providers.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, § 388-550-2531, filed 8/18/99, effective 9/18/99.]

     (2) ((In addition, MAA-approved Level B nursing facilities are subject to regular on-site surveys conducted by the department's aging and adult services administration (AASA).)) A provider of acute PM&R services must act on any report of substandard care or violation of the facility's medical staff bylaws and CARF standards. The provider must have and follow written procedures that:

     (a) Provide a resolution to either a complaint or grievance or both; and

     (b) Comply with applicable CARF standards for adults or pediatrics as appropriate.

     (3) A complaint or grievance regarding substandard conditions or care may be investigated by any one or more of the following:

     (a) The department of health (DOH);

     (b) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO);

     (c) CARF;

     (d) MAA; or

     (e) Other agencies with review authority for MAA programs.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, § 388-550-2541, filed 8/18/99, effective 9/18/99.]

     (d) Spinal cord injuries following the removal of a thoracic lumbar sacral orthosis after the client's first phase of acute rehabilitation)) (1) To qualify for acute PM&R services, a client must meet one of the conditions in subsection (2) of this section and have:

     (a) Extensive or complex medical needs, nursing needs, and therapy needs; and

     (b) A recent or new onset of a condition that causes an impairment in two or more of the following areas:

     (i) Mobility and strength;

     (ii) Self-care/ADLs (activities of daily living);

     (iii) Communication; or

     (iv) Cognitive/perceptual functioning.

     (2) To qualify for acute PM&R services, a client must meet the conditions in subsection (1) of this section and have a new or recent onset of one of the following conditions:

     (a) Brain injury caused by trauma or disease.

     (b) Spinal cord injury resulting in:

     (i) Quadriplegia; or

     (ii) Paraplegia.

     (c) Extensive burns.

     (d) Bilateral limb loss.

     (e) Stroke or aneurysm with resulting hemiplegia or cognitive deficits, including speech and swallowing deficits.

     (f) Multiple trauma (after the client is cleared to bear weight) with complicated orthopedic conditions and neurological deficits.

     (g) Severe pressure ulcers after skin flap surgery for a client who:

     (i) Requires close observation by a surgeon; and

     (ii) Is ready to mobilize or be upright in a chair.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, § 388-550-2551, filed 8/18/99, effective 9/18/99.]

     (5) MAA may authorize administrative day reimbursement for clients who do not meet requirements described in this section, or who stay in the facility longer than the community standard's length of stay. The administrative day rate is the statewide Medicaid average daily nursing facility rate as determined by the department)) (1) The medical assistance administration (MAA) requires prior authorization for acute PM&R services. The acute PM&R provider of services must obtain prior authorization:

     (a) Before admitting a client to the rehabilitation unit; and

     (b) For an extension of stay before the client's current authorized period of stay expires.

     (2) For an initial admit:

     (a) A client must:

     (i) Be eligible under one of the programs listed in WAC 388-550-2521, subject to the restrictions and limitations listed;

     (ii) Require acute PM&R services as determined in WAC 388-550-2551;

     (iii) Be medically stable and show evidence of physical and cognitive readiness to participate in the rehabilitation program; and

     (iv) Be willing and capable to participate at least three hours per day, seven days per week, in acute PM&R activities.

     (b) The acute PM&R provider of services must:

     (i) Submit a request for prior authorization to the MAA clinical consultation team by fax, electronic mail, or telephone as published in MAA's acute PM&R billing instructions; and

     (ii) Include sufficient medical information to justify that:

     (A) Acute PM&R treatment would effectively enable the client to obtain a greater degree of self-care and/or independence;

     (B) The client's medical condition requires that intensive twenty-four-hour inpatient comprehensive acute PM&R services be provided in an MAA-approved acute PM&R facility; and

     (C) The client suffers from severe disabilities including, but not limited to, neurological and/or cognitive deficits.

     (3) For an extension of stay:

     (a) A client must meet the conditions listed in subsection (2)(a) of this section and have observable and significant improvement; and

     (b) The acute PM&R provider of services must:

     (i) Submit a request for the extension of stay to the MAA clinical consultation team by fax, electronic mail, or telephone as published in MAA's acute PM&R billing instructions; and

     (ii) Include sufficient medical information to justify the extension and include documentation that the client's condition has observably and significantly improved.

     (4) If MAA denies the request for an extension of stay, the client must be transferred to an appropriate lower level of care as described in WAC 388-550-2501(3).

     (5) The MAA clinical consultation team approves or denies authorization for acute PM&R services for initial stays or extensions of stay based on individual circumstances and the medical information received. MAA notifies the client and the acute PM&R provider of a decision.

     (a) If MAA approves the request for authorization, the notification letter includes:

     (i) The number of days requested;

     (ii) The allowed dates of service;

     (iii) An MAA-assigned authorization number;

     (iv) Applicable limitations to the authorized services; and

     (v) MAA's process to request additional services.

     (b) If MAA denies the request for authorization, the notification letter includes:

     (i) The number of days requested;

     (ii) The reason for the denial;

     (iii) Alternative services available for the client; and

     (iv) The client's right to request a fair hearing. (See subsection (7) of this section.)

     (6) The acute PM&R facility staff must:

     (a) Discuss MAA's authorization decision with the client and/or the client's family; and

     (b) Document in the client's medical record that MAA's decision was discussed with the client and/or the client's family.

     (7) A client who does not agree with a decision regarding acute PM&R services has a right to a fair hearing under chapter 388-02 WAC. After receiving a request for a fair hearing, MAA may request additional information from the client and the facility, or both. After MAA reviews the available information, the result may be:

     (a) A reversal of the initial MAA decision;

     (b) Resolution of the client's issue(s); or

     (c) A fair hearing conducted per chapter 388-02 WAC.

     (8) MAA may authorize administrative day(s) for a client who:

     (a) Does not meet requirements described in subsection (3) of this section;

     (b) Stays in the facility longer than the "community standards length of stay"; or

     (c) Is waiting for a discharge destination or a discharge plan.

     (9) MAA does not authorize acute PM&R services for a client who:

     (a) Is deconditioned by a medical illness or by surgery; or

     (b) Has loss of function primarily as a result of a psychiatric condition(s); or

     (c) Has had a recent surgery and has no complicating neurological deficits. Examples of surgeries that do not qualify a client for inpatient acute PM&R services without extenuating circumstances are:

     (i) Single amputation;

     (ii) Single extremity surgery; and

     (iii) Spine surgery.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, § 388-550-2561, filed 8/18/99, effective 9/18/99.]

     (1) ((A Level A)) MAA pays a rehabilitation facility ((is paid by MAA)) according to((:

     (a))) the individual hospital's current ratio of costs-to-charges as described in WAC 388-550-4500, Payment method--RCC((; and

     (b) MAA's fee schedule as described in WAC 388-550-6000, Payment--Outpatient hospital services)).

     (2) ((Level A)) Inpatient acute PM&R room and board includes, but is not limited to:

     (a) Facility use;

     (b) Medical social services;

     (c) Bed and standard room furnishings; and

     (d) Dietary and nursing services.

     (3) When MAA authorizes administrative day(s) for a client as described in WAC 388-550-2561(8), MAA reimburses the facility:

     (a) The administrative day rate; and

     (b) For pharmaceuticals prescribed in the client's use during the administrative portion of the client's stay.

     (4) The department pays for transportation services provided to a client receiving acute PM&R services in a hospital-based facility according to chapter 388-546 WAC.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, § 388-550-3381, filed 8/18/99, effective 9/18/99.]

     The following section of the Washington Administrative Code is repealed:

WAC 388-550-3401

How MAA pays acute PM&R facilities for Level B services.

© Washington State Code Reviser's Office