WSR 15-08-090
(Washington Apple Health)
[Filed March 31, 2015, 2:11 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 15-04-095.
Title of Rule and Other Identifying Information: WAC 182-553-500 Home infusion therapy/parenteral nutrition programCoverage, services, limitations, prior authorization, and reimbursement.
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Conference Room, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at or directions can be obtained by calling (360) 725-1000), on May 5, 2015, at 10:00 a.m.
Date of Intended Adoption: Not sooner than May 6, 2015.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail, fax (360) 586-9727, by 5:00 p.m. on May 5, 2015.
Assistance for Persons with Disabilities: Contact Kelly Richters by April 27, 2015, TTY (800) 848-5429 or (360) 725-1307 or e-mail
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending the rule to include continuous glucose monitoring systems among equipment that this program pays for.
Reasons Supporting Proposal: Adding new language regarding continuous glucose monitoring systems will make the rule consistent with other chapters in WAC.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Statute Being Implemented: RCW 41.05.021, 41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Sean Sullivan, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1344; Implementation and Enforcement: Lisa Humphrey, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1617.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has analyzed the proposed rules and concludes they do not impose more than minor costs for affected small businesses.
A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
March 31, 2015
Jason R. P. Crabbe
Rules Coordinator
AMENDATORY SECTION (Amending WSR 12-16-059, filed 7/30/12, effective 8/30/12)
WAC 182-553-500 Home infusion therapy((/)) and parenteral nutrition program—Coverage, services, limitations, prior authorization, and reimbursement.
(1) The home infusion therapy((/)) and parenteral nutrition program covers the following for eligible clients, subject to the limitations and restrictions listed:
(a) Home infusion supplies, limited to one month's supply per client, per calendar month.
(b) Parenteral nutrition solutions, limited to one month's supply per client, per calendar month.
(c) One type of infusion pump, one type of parenteral pump, and((/or)) one type of insulin pump per client, per calendar month and as follows:
(i) All rent-to-purchase infusion, parenteral, and((/or)) insulin pumps must be new equipment at the beginning of the rental period.
(ii) The agency covers the rental payment for each type of infusion, parenteral, or insulin pump for up to twelve months. ((())The agency considers a pump purchased after twelve months of rental payments.(()))
(iii) The agency covers only one purchased infusion pump or parenteral pump per client in a five-year period.
(iv) The agency covers only one purchased insulin pump per client in a four-year period.
(2) Covered supplies and equipment that are within the described limitations listed in subsection (1) of this section do not require prior authorization for reimbursement.
(3) The agency pays for FDA approved continuous glucose monitoring systems and related monitoring equipment and supplies with prior authorization when the client:
(a) Is either younger than nineteen years of age or enrolled in a continuous glucose monitoring trial. The trial must be approved by an institutional review board under RCW 70.02.010;
(b) Has diabetes mellitus and is insulin dependent;
(c) Has had a severe episode of hypoglycemia (blood glucose less than or equal to 50mg/dl) either requiring assistance from another person or complicated by a hypoglycemia-induced seizure;
(d) Has first tried a seventy-two-hour monitoring period;
(e) Has recurrent unexplained severe hypoglycemic events despite modifications in therapy;
(f) Is followed by a pediatric endocrinologist;
(g) Has A1c target goals deemed appropriate by a physician; and
(h) Has submitted results of self-monitoring of blood glucose levels taken at least four times per day.
(4) Requests for supplies ((and/))or equipment that exceed the limitations or restrictions listed in this section require prior authorization and are evaluated on an individual basis according to the provisions of WAC 182-501-0165 and 182-501-0169.
(((4))) (5) The agency may adopt policies, procedure codes, and((/or)) rates ((that are)) inconsistent with those set by medicare ((if the agency determines that such actions are necessary)).
(((5))) (6) Agency reimbursement for equipment rentals and purchases includes the following:
(a) Instructions to a client ((or)), a caregiver, or both, on the safe and proper use of equipment provided;
(b) Full service warranty;
(c) Delivery and pickup; and
(d) Setup, fitting, and adjustments.
(((6) Except as provided in subsection (6) of this section, the)) (7) The agency does not pay separately for home infusion supplies and equipment or parenteral nutrition solutions, except:
(a) When a client resides in a state-owned facility (((i.e.)) e.g., state school, a developmental disabilities (((DD))) facility, a mental health facility, Western State Hospital, ((and)) or Eastern State Hospital).
(b) When a client has elected and is eligible to receive the agency's hospice benefit, unless ((both of the following apply)):
(i) The client has a preexisting diagnosis that requires parenteral support; and
(ii) The preexisting diagnosis is not related to the diagnosis that qualifies the client for hospice.
(((7))) (8) The agency pays separately for a client's infusion pump, parenteral nutrition pump, insulin pump, solutions, and((/or)) insulin infusion supplies when the client:
(a) Resides in a nursing facility; and
(b) Meets the criteria in WAC 182-553-300.