WSR 18-11-137
[Filed May 23, 2018, 11:11 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 18-07-093.
Title of Rule and Other Identifying Information: WAC 182-552-1000 Respiratory care—Covered—Respiratory and ventilator equipment and supplies.
Hearing Location(s): On June 26, 2018, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Sue Crystal Conference Room 106A, 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.
Date of Intended Adoption: Not sooner than June 27, 2018.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email, fax 360-586-9727, by June 26, 2018.
Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, TTY 800-848-5429 or 711, email, by June 22, 2018.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is revising this section to (1) clarify the clinical criteria for the rental of a back-up ventilator; (2) revise the authorization requirements for ventilators; and (3) remove the outdated clinical criteria for ventilators for clients seventeen years of age and younger.
Reasons Supporting Proposal: See purpose.
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: Vance Taylor, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1344; Implementation and Enforcement: Joan Chappell, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1071.
A school district fiscal impact statement is not required under RCW 28A.305.135.
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.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The updates to these rules do not impose additional compliance costs or requirements on providers. The agency is reducing the requirements for authorization on all ventilators.
May 23, 2018
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 12-14-022, filed 6/25/12, effective 8/1/12)
WAC 182-552-1000 ((Respiratory care))CoveredRespiratory and ventilator equipment and supplies.
(1) The medicaid agency covers the rental of a ventilator, equipment, and ((related)) disposable ventilator supplies when the ((ventilator is)) client requires periodic or continuous mechanical ventilation for the treatment of chronic respiratory failure (((chronic carbon dioxide retention))) resulting from hypoxemia or hypercapnia.
(2) The ((medicaid)) agency's payment for the monthly rental ((rate)) includes ventilator maintenance and accessories including, but not limited to, humidifiers, nebulizers, alarms, temperature probes, batteries, chargers, adapters, connectors, fittings, tubing, disposable circuits, and filters. The ((medicaid)) agency does not pay separately for ventilator accessories unless the client owns the ventilator system, see subsection (5) of this section.
(3) To receive payment, ventilators, equipment, and related disposable supplies must:
(a) Be used exclusively by the client for whom it is requested;
(b) Be FDA-approved; and
(c) Not be included in any other reimbursement methodology such as, but not limited to, a diagnosis-related group (DRG).
(4) The ((medicaid)) agency pays for a back-up (secondary) ventilator at fifty percent of the monthly rental rate when one or more of the following clinical criteria are met:
(a) The client cannot maintain spontaneous or adequate ventilations for four or more consecutive hours;
(b) The client lives in an area where a replacement ventilator cannot be provided within two hours;
(c) The client requires mechanical ventilation during mobility as prescribed in their plan of care.
(5) The ((medicaid)) agency pays for the purchase of the following replacement ventilator accessories only for client-owned ventilator systems:
(a) Gel-cell battery charger - One every twenty-four months;
(b) ((Gel-cel)) Gel-cell heavy-duty battery - One every twenty-four months;
(c) Battery cables - Once every twenty-four months; and
(d) Breathing circuits - Four every thirty days.
(6) ((Pressure support ventilators.
(a) For clients eighteen years of age and older, the medicaid agency requires prior authorization;
(b) For clients seventeen years of age and younger, the medicaid agency requires expedited prior authorization (EPA).
(i) The following criteria must be met in order to use the EPA process:
(A) The client is currently using a pressure support ventilator;
(B) The client must be able to take spontaneous breaths;
(C) There must be an authorized prescriber's order for the pressure support setting; and
(D) The client must be utilizing the ventilator in the pressure support mode.
(ii) If the client has no clinical potential for weaning, the medicaid agency's EPA is valid for twelve months; or
(iii) If the client has the potential to be weaned, then the medicaid agency's EPA is valid for six months;
(iv) To continue using EPA after the valid time period has lapsed, a vendor must document in the client's file that the client continues to meet the EPA criteria for a pressure support ventilator.)) All ventilators require expedited prior authorization (EPA), as described in WAC 182-552-1375.
(a) At the time of authorization, the following information must be documented in the client's record and made available to the agency upon request:
(i) Medical history, unless request is for continuation of services;
(ii) Diagnosis and degree of impairment;
(iii) Degree of ventilatory support required; and
(iv) Ventilator settings and parameters including mode and type of ventilator ordered at the time of the authorization.
(b) If the client has no clinical potential for being weaned from ventilatory support, the EPA is valid for twelve months;
(c) If the client has the potential to be weaned, the EPA is valid for six months.