
•	Clarify that home health aide services are delegated by a registered nurse.
•	Clarify that home health skilled services must be provided by a medicare-certified home health agency.
•	Identify who may receive reimbursement for providing home health skilled nursing services.
•	Allow providers with prescribing authority to order home infusions and manage a client's home infusion care.
•	Clarify that a person with a functioning gastrointestinal tract is eligible for parenteral nutrition services when the services are medically necessary.
•	Clarify that providers must be enrolled with HCA with a signed core provider agreement or as a servicing provider.
•	Provide that the client's lab values must be part of the client's file as suggested by accepted standards of care or professional society recommendations.

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to subchapter II:

"Acute care" means care provided by a home health agency for clients who are not medically stable or have not attained a satisfactory level of rehabilitation. These clients require frequent intervention by a registered nurse or licensed therapist.

"Authorized practitioner" means:

(a) A physician, nurse practitioner, clinical nurse specialist, or physician assistant who may order and conduct home health services, including face-to-face encounter services; or

(b) A certified nurse midwife under 42 C.F.R. 440.70 when furnished by a home health agency that meets the conditions of participation for medicare who may conduct home health services, including face-to-face encounter services.

"Brief skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs only one of the following activities during a visit to a client:

(a) An injection;

(b) Blood draw; or

"Chronic care" means long-term care for medically stable clients.

"Electronic visit verification (EVV)" means, with respect to home health services, a system under which in-home visits conducted as part of delivery of such services are electronically verified with respect to:

(a) The type of service performed;

(b) The individual receiving the service;

(d) The location of service delivery;

(e) The individual providing the service; and

(f) The time the service begins and ends.

"Full skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs one or more of the following activities during a visit to a client:

(a) Observation;

(b) Assessment;

(d) Teaching;

(e) Training;

(f) Management; and

(g) Evaluation.

"Home health agency" means an agency or organization that attests to the satisfaction of the medicaid agency that it meets the requirements for participation in medicare or is certified under the medicare program to provide comprehensive health care on an intermittent or part-time basis to a patient in any setting where the patient's normal life activities take place.

"Home health aide" means a person registered or certified as a nursing assistant under chapter 18.88 RCW who, under the direction and supervision of a registered nurse or licensed therapist, assists in the delivery of nursing or therapy related activities, or both.

"Home health aide services" means services ((provided by a home health aide only when a client has an acute, intermittent, short-term need for the services of a registered nurse, physical therapist, occupational therapist, or speech therapist who is employed by or under contract with a home health agency. These services are provided under the supervision of the previously identified authorized practitioners and include, but are not limited to,))such as ambulation and exercise, bathing, assistance with self-administered medications, reporting changes in a client's condition and needs, ((and)) completing appropriate records, and other duties delegated by a registered nurse.

"Home health skilled services" means skilled health care (nursing, specialized therapy, and home health aide) services provided on an intermittent or part-time basis by a medicare-certified home health agency. See also WAC 182-551-2000. Home health skilled services do not include self-administered services or services provided by a trained caregiver.

"Long-term care" is a generic term referring to various programs and services, including services provided in home and community settings, administered directly or through contract by the department of social and health services' (DSHS) ((division of)) developmental ((disabilities (DDD) or aging and long-term support administration (ALTSA)))disabilities community services (DDCS) or home and community living administration (HCLA) through home and community services (HCS).

"Medical social services" are services delivered by a medical social worker that are intended to resolve social or emotional problems that are expected to be an impediment to the effective treatment of the client's medical condition or rate of recovery.

"Medical social worker" has the same meaning given for "social worker" in WAC 246-335-510.

"Plan of care (POC)" (also known as "plan of treatment (POT)") means a written plan of care that is established and periodically reviewed and signed by both an authorized practitioner and a home health agency provider. The plan describes the home health care to be provided in any setting where the client's normal life activities take place. See WAC 182-551-2210.

"Review period" means the three-month period the medicaid agency assigns to a home health agency, based on the address of the agency's main office, during which the medicaid agency reviews all claims submitted by that home health agency.

"Specialized therapy" means skilled therapy services provided to clients that include:

(a) Physical;

(b) Occupational; or

(See WAC 182-551-2110.)

"Telemedicine" - See WAC 182-501-0300 and 182-551-2125.

(1) The medicaid agency covers home health skilled nursing services up to service limitations without prior authorization. See WAC 182-501-0169 for information on limitation extension.

(2) The home health skilled nursing services must be furnished by a qualified provider in any setting where normal life activities take place.

(3) The medicaid agency pays for the following home health skilled nursing services, subject to program rules and the provisions in this section:

(a) Full skilled nursing services that require the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse, if the services involve one or more of the following:

(i) Observation;

(ii) Assessment;

(iii) Treatment;

(iv) Teaching;

(v) Training;

(vi) Management; and

(vii) Evaluation.

(b) A brief skilled nursing visit if only one of the following activities is performed during the visit:

(i) An injection;

(ii) Blood draw; or

(iii) Placement of medications in containers (e.g., envelopes, cups, medisets).

(i) Is willing and capable of learning and managing the client's infusion care; or

(ii) Has a volunteer caregiver willing and capable of learning and managing the client's infusion care))of medications or parenteral nutrition by providers appropriately trained to provide the services and acting within the scope of their license.

(d) Infant phototherapy for an infant diagnosed with hyperbilirubinemia:

(i) When provided by a medicaid agency-approved home health agency with an infant phototherapy provider; and

(ii) For up to five skilled nursing visits per infant.

(e) Limited high-risk obstetrical services:

(i) For a medical diagnosis that complicates pregnancy and may result in a poor outcome for the birth parent, unborn, or newborn;

(ii) For up to three home health visits per pregnancy if enrolled in or referred to a first steps maternity support services (MSS) provider. The visits are provided by a registered nurse who has either:

(A) National perinatal certification; or

(B) A minimum of one year of labor, delivery, and postpartum experience at a hospital within the last five years.

(4) The medicaid agency pays for up to two skilled nursing visits, per client, per day.

(5) Home health skilled nursing services do not include self-administered services and services administered by a trained caregiver.

(6) The agency does not reimburse for self-administered services or services administered by a trained caregiver, except for:

(a) Covered outpatient drugs, devices, and drug-related supplies, as described in WAC 182-530-2000; and

(b) Other supplies used to administer a drug.

(1) The medicaid agency does not cover the following home health services under the home health program:

(a) Chronic long-term care skilled nursing visits or specialized therapy visits for a medically stable client when a long-term care skilled nursing plan or specialized therapy plan is in place through the department of social and health services' ((aging and long-term support administration (ALTSA)))home and community living administration (HCLA).

(i) Prior to ((ALTSA))HCLA implementing a long-term care skilled nursing plan or specialized therapy plan, the medicaid agency may consider a short-term authorization of these services as an exception to rule (ETR); and

(ii) Any services authorized are subject to the provisions in this section and other applicable WAC.

(b) Social work services that are not "medical social services" as defined in WAC 182-551-2010 or listed as covered in WAC 182-551-2115.

(d) Prenatal and postpartum skilled nursing services, except as listed under WAC 182-551-2100.

(e) Well-baby follow-up care.

(f) Services performed in hospitals, correctional facilities, skilled nursing facilities, or a residential facility with skilled nursing services available.

(g) Health care for a medically stable client.

(h) Home health specialized therapies and home health aide visits for alien emergency medical (AEM) clients in the following programs:

(i) Categorically needy - Emergency medical only; and

(ii) Medically needy - Emergency medical only.

(2) The medicaid agency evaluates a request for home health services that are listed as noncovered, as defined by WAC 182-500-0020 and 182-500-0075:

(a) For a person age 21 and older, under WAC 182-501-0160;

(b) For a person age 20 and younger, under the early ((and)) periodic screening, diagnosis, and treatment (EPSDT) ((provisions in))program; see chapter 182-534 WAC; and

(1) To receive home infusion therapy and parenteral nutrition, subject to the limitations and restrictions in this section and other applicable WAC, a person must be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060.

(2) Persons enrolled in an agency-contracted managed care organization (MCO) are eligible for home infusion therapy and parenteral nutrition through that plan.

(3) Persons eligible for home health program services may receive home infusion related services according to WAC 182-551-2000 through 182-551-3000.

(4) To receive home infusion therapy, a person must meet all the following requirements:

(a) Have a prescription written ((physician order))by a provider with prescribing authority for all solutions and medications to be administered.

(b) ((Be able to manage their infusion in one of the following ways:

(i) Independently;

(ii) With a volunteer caregiver who can manage the infusion; or

(iii) By choosing to self-direct the infusion with a paid caregiver (see WAC 388-71-0580).

(c))) Be clinically stable and have a condition that does not warrant hospitalization.

(((d)))(c) Agree to comply with the protocol established by the infusion therapy provider for home infusions. If the person is not able to comply, the person's caregiver may comply.

(((e)))(d) Consent, if necessary, to receive solutions and medications administered in the home through intravenous, enteral, epidural, subcutaneous, or intrathecal routes. If the person is not able to consent, the person's legal representative may consent.

(((f)))(e) Reside in a residence that has adequate accommodations for administering infusion therapy including:

(i) Running water;

(ii) Electricity;

(iii) Telephone access; and

(iv) Receptacles for proper storage and disposal of drugs and drug products.

(5) To receive parenteral nutrition, a person must meet the conditions in subsection (4) of this section and:

(a) Have one of the following that prevents oral or enteral intake to meet the person's nutritional needs:

(i) Hyperemesis gravidarum; or

(ii) An impairment involving the gastrointestinal tract that lasts three months or longer.

(b) Be unresponsive to medical interventions other than parenteral nutrition; and

(6) A person who has a functioning gastrointestinal tract is ((not)) eligible for parenteral nutrition program services when ((the need for parenteral nutrition is only due to:

(a) A swallowing disorder;

(b) Gastrointestinal defect that is not permanent unless the person meets the criteria in subsection (7) of this section;

(d) A cognitive disorder (such as dementia) that impairs food intake;

(e) A physical disorder (such as cardiac or respiratory disease) that impairs food intake;

(f) A side effect of medication; or

(g) Renal failure or dialysis, or both))those services are medically necessary.

(7) A person with a gastrointestinal impairment that is expected to last less than three months is eligible for parenteral nutrition only ((if))when documented by a medical provider and when:

(a) ((The person's physician or appropriate medical provider has documented in the person's medical record the gastrointestinal impairment is expected to last less than three months;

(b))) The person meets all the criteria in subsection (4) of this section;

(((c)))(b) The person has a written ((physician))provider order that documents the person is unable to receive oral or tube feedings; ((and))or

(((d)))(c) It is medically necessary for the gastrointestinal tract to be totally nonfunctional for a period of time.

(8) A person is eligible to receive intradialytic parenteral nutrition (IDPN) solutions when:

(a) The parenteral nutrition is not solely supplemental to deficiencies caused by dialysis; and

(b) The person meets the criteria in subsection (4) and (5) of this section and other applicable WAC.

(1) Eligible providers of home infusion supplies and equipment and parenteral nutrition solutions must:

(a) ((Have))Be enrolled with the agency with a signed core provider agreement ((with the medicaid agency))or as a servicing provider; and

(b) Be one of the following provider types:

(i) Pharmacy provider;

(ii) Durable medical equipment (DME) provider; or

(iii) Infusion therapy provider.

(2) The agency pays eligible ((providers for)) home infusion providers for supplies and equipment and parenteral nutrition solutions only when the providers:

(a) Are able to provide home infusion therapy within their scope of practice;

(b) Have evaluated each client ((in collaboration with the client's physician, pharmacist, or nurse)) to determine whether home infusion therapy and parenteral nutrition is an appropriate course of action;

(d) Have assessed the client and obtained a written ((physician))provider order for all solutions and medications administered to the client in the client's residence or in a dialysis center through intravenous, epidural, subcutaneous, or intrathecal routes;

(e) Meet the requirements in WAC 182-502-0020, including keeping legible, accurate, and complete client charts, and providing the following documentation in the client's medical file:

(i) For a client receiving infusion therapy, the file must contain:

(A) A copy of the written prescription for the therapy;

(B) The client's age, height, and weight; and

(ii) For a client receiving parenteral nutrition, the file must contain:

(A) All the information listed in (e)(i) of this subsection;

(B) Oral or enteral feeding trials and outcomes, if applicable;

(D) The monitoring and reviewing of the client's lab values:

(I) ((At the initiation of therapy))As suggested by accepted standards of care or professional society recommendations; and

(II) ((At least once per month; and

(III))) When the client, the client's lab results, or both, are unstable.