SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: Revisions to this rule are necessary to: (1) Fully meet the legislatively mandated appropriation reduction in section 1109, chapter 564, Laws of 2009 (ESHB 1244) for maternity support services (first steps program) and infant case management (ICM) services for fiscal years 2010-2011; (2) further clarify the department's coverage policy; specifically, the rules amend sections in chapter 388-533 WAC and reduce the quantity of services clients qualify for; and (3) update and clarify other ICM services policy.
Citation of Existing Rules Affected by this Order: Amending WAC 388-533-0360, 388-533-0365, 388-533-0370, 388-533-0375, 388-533-0380, 388-533-0385, and 388-533-0386.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.760 through 74.09.910.
Other Authority: Section 1109, chapter 564, Laws of 2009 (ESHB 1244).
Adopted under notice filed as WSR 10-08-083 on April 6, 2010.
A final cost-benefit analysis is available by contacting June Hershey, DSHS/HRSA, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 725-1293, fax (360) 664-4371, e-mail email@example.com.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 7, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 7, Repealed 0.
Date Adopted: May 21, 2010.
Susan N. Dreyfus
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0360, filed 6/10/04, effective 7/11/04.]
"Infant case management (ICM)" -- The program that provides case management services to eligible high-risk infants and their families. Eligibility for ICM may be established at the end of the maternity cycle up to the end of the month of the baby's first birthday)) infant case management (ICM).
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0365, filed 6/10/04, effective 7/11/04.]
The infant must)) Be covered under one of the
medical assistance programs listed in WAC 388-533-0320
(1)(( (a) of this chapter));
The parent(s) must need assistance in accessing or
providing care for the infant)) Meet the age requirement for
ICM which is the day after the maternity cycle (defined in WAC 388-533-0315) ends, through the last day of the month of the
infant's first birthday; (( and))
At least one or more of the following criteria
(i) The parent(s) are unable to care for infant specifically due to at least one of the following:
(A) Incarceration of the mother within the last year;
(B) Low functioning ability (e.g., needs repeated instructions, not attuned to infant cues, leaves infant with inappropriate caregivers, parent has the equivalent of less than an eighth grade education);
(C) Unstable mental health issue (regardless of whether the mental health issue is being treated or not);
(D) Physical impairment;
(E) Infant's mother is experiencing postpregnancy depression or mood disorder or has a history of depression/mood disorder;
(F) Infant's parent(s) are unable to access resources due to age (nineteen years of age or younger);
(G) Social isolation (e.g., family is new to the community, parent(s) do not have a support system, family moves frequently, lack of supportive living environment);
(H) Inability to access resources due to language or cultural barrier.
(ii) The infant's safety is a concern specifically due to at least one of the following:
(A) Domestic or family violence in present or past relationship that keeps the parent(s) feeling unsafe;
(B) Substance abuse by the infant's mother and/or father that is impacting ability to parent;
(C) Secondhand smoke exposure to the infant;
(D) Child protective service involvement within the last year or mother/father had parental rights terminated in the past;
(E) Unstable living situation (e.g., homelessness, couch surfing, unsafe conditions, no cooking facilities, heat, or water).
(iii) The infant's health is a concern specifically due to at least one of the following:
(A) Low birth weight -- less than five and one half pounds;
(B) Premature birth -- less than thirty-seven weeks gestation;
(C) Failure to thrive (e.g., baby is not gaining weight, significant feeding difficulty, no eye contact, or baby is listless);
(D) Multiple births (twins, triplets. etc.);
(E) Excessive fussiness or infant has irregular sleeping patterns (e.g., parent(s)' sleep deprivation, exhaustion and/or need for respite childcare);
(F) Infant has an identified medical problem or disability)) Reside with at least one parent (see WAC 388-533-0315 for definition of parent);
(d) Have a parent(s) who needs assistance in accessing medical, social, educational and/or other services to meet the infant's basic health and safety needs; and
(e) Not be receiving any case management services funded through Title XIX medicaid that duplicate ICM services.
(2) Infants who meet the eligibility criteria in subsection (1) of this section, and the infant's parent(s), are eligible to receive:
(a) An in-person screening by a provider who meets the criteria established in WAC 388-533-0375. Infants and their parent(s) are screened for risk factors related to issues that may impact the infant's welfare, health, and/or safety.
(b) Up to the maximum number of ICM units of service allowed per client as determined by the department and published in the department's current billing instructions and/or numbered memoranda. The department may determine the maximum number of units allowed per client when directed by the legislature to achieve targeted expenditure levels for payment in any specific biennium.
(3) Clients meeting the eligibility criteria in ((
WAC 388-533-0370(1))) subsection (1) of this section who are
enrolled in (( an MAA)) a department-contracted managed care
plan are eligible for ICM services outside their plan. (( ICM
services delivered outside the managed care plan are
reimbursed on a fee-for-service basis and subject to the same
program rules as apply to nonmanaged care clients.))
(4) See chapter 388-534 WAC for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.
(5) Clients receiving ICM before July 1, 2009, are subject to the transition plan as determined and published by the department in numbered memoranda.
(6) Clients who do not agree with a department decision regarding eligibility for ICM have a right to a fair hearing under chapter 388-02 WAC.
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0370, filed 6/10/04, effective 7/11/04.]
(a) Services are to be delivered in area of geographic need as determined by MAA/DOH; and
(b) Provider must:
(i) Deliver both MSS and ICM services;
(ii) Provide services in both office and home visit settings; and
(iii) Assure maintenance of staffing requirements and delivery of service according to program design.
(2) To participate in the ICM program, a provider must:
(a) Comply with the clinical supervision/clinical guidelines as prescribed in the assurances document;
(b) Notify the MAA program manager when there is a staff change in a designated position;
(c) Ensure that all newly hired staff receive an orientation to First Steps services as soon as possible, but not later than sixty days from the hire date; and
(d) Submit billings as instructed in MAA's published MSS/ICM billing instructions.
(3) To be reimbursed by MAA for ICM, a provider must:
(a) Meet the requirements in chapter 388-502 WAC, Administration of medical programs -- Providers rules;
(b) Have a completed, approved MSS/ICM assurances document, signed by an officer or employee qualified to sign on behalf of the provider, on file with MAA; and
(c) Ensure that staff meet the minimum qualifications for the ICM roles they perform)) Infant case management (ICM) services can be provided only by a qualified person who is employed by an agency or entity that meets the requirements in WAC 388-533-0325. Additionally, to qualify as an ICM provider, the person must meet at least one of the following:
(1) Be a current member of the maternity support services (MSS) interdisciplinary team;
(2) Have a Bachelor of Arts, Bachelor of Science, or higher degree, plus at least one year of full-time experience working in one or more of the following areas:
(a) Community social services;
(b) Public health services;
(c) Crisis intervention;
(d) Outreach and referral programs; or
(e) Other social services-related fields.
(3) Have an Associate of Arts degree, or an associate's degree in a closely allied field, plus at least two years of full-time experience in an area listed in (1) of this section. In addition, at least once per calendar month, the department requires a provider qualifying under this subsection to be under the supervision of a clinical staff person who meets the criteria in (1) of this section.
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0375, filed 6/10/04, effective 7/11/04.]
(2) The ICM program reimburses approved providers for case management including:)) The department covers infant case management (ICM) services subject to the restrictions and limitations in this section and other applicable WAC.
(2) Covered services include:
Assessing risk and need)) An initial in-person
screening for ICM services which includes an assessment of
risk factors, and the development of an individualized care
Reviewing and updating the infant and parent(s)
service plan)) Case management services and care coordination;
Referring and)) Linking and referring the
(( client)) infant and parent(s) to other (( agencies)) services
or resources; (( and))
(d) Advocating for the ((
client with other agencies))
infant and parent(s);
(e) Follow-up contact(s) with the parent(s) to ensure the care plan continues to meet the needs of the infant and parent(s); and
(f) Additional services as determined and published in the maternity support services/infant case management (MSS/ICM) billing instructions.
The case management activities listed in WAC 388-533-0380(2) are covered under the ICM program only when:
(a) Documented in the client's record;
(b) Provided on an individual basis in a face-to-face encounter;
(c) Performed by a qualified staff person acting within her/his area of expertise; and
(d) Provided according to program design as described in the MSS/ICM assurances document)) The department pays for covered ICM services according to WAC 388-533-0386.
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0380, filed 6/10/04, effective 7/11/04.]
(a) Any direct delivery of services other than case management activities listed in WAC 388-533-0380(2); and
(b) Any service provided by staff not qualified to deliver the service)) department covers only those services that are listed in WAC 388-533-0380.
(2) The department evaluates ((
requests)) a request for
(( services listed as)) any noncovered service under the
provisions of WAC 388-501-0160. When early periodic
screening, diagnosis and treatment (EPSDT) applies, the
department evaluates a request for a noncovered service
according to the process in WAC 388-501-0165 to determine if
it is medically necessary, safe, effective, and not
experimental (see chapter 388-534 WAC for EPSDT rules).
[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-533-0385, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0385, filed 6/10/04, effective 7/11/04.]
ICM is reimbursed in units of service with one unit
being equal to fifteen minutes of service;
(2) MAA reimburses:
(a) No more than six ICM units per month, per client; and
(b) No more than forty ICM units total per client through the end of the month of the baby's first birthday; and
(c) Only for services billed using the approved ICM procedure code and modifier identified in MAA's published MSS/ICM billing instructions)) ICM services must be:
(a) Provided to a client who meets the eligibility requirements in WAC 388-533-0370;
(b) Provided by a person who meets the criteria established in WAC 388-533-0375;
(c) Provided according to the department's current published maternity support services/infant case management (MSS/ICM) billing instructions and/or numbered memoranda;
(d) Documented in the infant's and/or infant's parent(s) record or chart; and
(e) Billed using:
(i) The eligible infant's department-assigned client identification number;
(ii) The appropriate procedure codes and modifiers identified in the department's current published MSS/ICM billing instructions and/or numbered memoranda; and
(iii) The department-assigned MSS/ICM provider number.
(2) The department:
(a) Pays ICM services in units of time with one unit being equal to fifteen minutes of one-to-one service delivered face-to-face;
(b) When directed by the legislature to achieve targeted expenditure levels for payment of maternity support services for any specific biennium, may determine the maximum number of units allowed per client; and
(c) Publishes the maximum number of units allowed per client in the MSS/ICM billing instructions and/or numbered memoranda.
(3) For a client enrolled in a managed care plan who is eligible to receive ICM, the department pays ICM services:
(a) Delivered outside the plan on a fee-for-service basis as described in this section; and
(b) Subject to the same program rules that apply to a client who is not enrolled in a managed care plan.
(4) Limitation extension requests to exceed the number of allowed ICM units of service may be authorized according to WAC 388-501-0169.
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0386, filed 6/10/04, effective 7/11/04.]