HEALTH CARE AUTHORITY
[Filed July 2, 2018, 9:37 a.m., effective August 2, 2018]
Effective Date of Rule: Thirty-one days after filing.
Purpose: 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for the rental of a back-up ventilator; (2) revise the authorization requirements for ventilators; and (3) remove the outdated clinical criteria for ventilators for clients seventeen years of age and younger.
Citation of Rules Affected by this Order: Amending WAC 182-552-1000.
Adopted under notice filed as WSR 18-11-137 on May 23, 2018.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: July 2, 2018.
AMENDATORY SECTION(Amending WSR 12-14-022, filed 6/25/12, effective 8/1/12)
WAC 182-552-1000((Respiratory care—))Covered—Respiratory 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.