reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7450 - OPPS budget target adjustor

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency may apply an outpatient prospective
				  payment system (OPPS) budget target adjustor to the enhanced ambulatory patient
				  group (EAPG) payment. The agency calculates the OPPS budget target adjustor
				  based on legislative direction to achieve the legislature's targeted
				  expenditure levels for outpatient hospital services. The legislative direction
				  may take the form of express language in the Biennial Appropriations Act or may
				  be reflected in the level of funding appropriated to the agency in the Biennial
				  Appropriations Act.
11-14-075, recodified as §
											182-550-7450, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090,
					 74.09.500, and 2009-11 Omnibus
					 Operating Budget (ESHB 1244). 09-12-062, § 388-550-7450, filed 5/28/09,
					 effective 7/1/09.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7500 - OPPS rate

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency calculates hospital-specific outpatient prospective payment system
				(OPPS) rates using all of the following:
(a) A
				base conversion factor established by the agency;
(b) An adjustment for direct graduate medical
				education (DGME); and
(c) The
				latest wage index information established and published by the centers for
				medicare and medicaid services (CMS) when the OPPS rates are set for the
				upcoming year. Wage index information reflects labor costs in the cost-based
				statistical area (CBSA) where a hospital is located.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7550 - OPPS payment enhancements

Current through Register Vol. 24-14, July 15, 2024
(1)
				Pediatric adjustment.
(a) The medicaid agency
				establishes a policy adjustor to be applied to all enhanced ambulatory patient
				group (EAPG) services for clients under age 18 years.
(b) Effective July 1, 2014, this adjustor
				equals one point thirty-five (1.35).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-7600 - OPPS payment calculation

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medicaid agency calculates the enhanced ambulatory patient group (EAPG)
				payment as follows:
EAPG payment =
EAPG relative weight x
Hospital-specific conversion factor x
Discount factor (if applicable) x
Policy adjustor (if applicable)
(2) The total OPPS claim payment is the sum
				of the EAPG payments plus the sum of the allowed amounts for each non- EAPG
				service.
(3) If a client's
				third-party liability insurance has made a payment on a service, the agency
				subtracts any such payments made from the medicaid allowed amount.
11-14-075, recodified as §
											182-550-7600, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090,
					 74.09.500, and 2009-11 Omnibus
					 Operating Budget (ESHB 1244). 09-12-062, § 388-550-7600, filed 5/28/09,
					 effective 7/1/09. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-13-100, §
					 388-550-7600, filed 6/20/07, effective 8/1/07; 04-20-061, § 388-550-7600,
					 filed 10/1/04, effective 11/1/04.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-8000 - Hospital safety net program (HSNP)-Purpose

Current through Register Vol. 24-14, July 15, 2024
Chapter 74.60 RCW establishes the hospital safety net program
				  (HSNP). The HSNP provides funding that is used solely to increase funding from
				  all other sources and support additional payments to hospitals as authorized by
				  chapter 74.60 RCW. The medicaid agency has authority to issue rules associated
				  with the HSNP under
				  RCW
				  41.05.021 (1)(m)(iv) and
				  74.60.050(1).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-8100 - Assessment notices-Process and timelines

Current through Register Vol. 24-14, July 15, 2024
(1)
Notification.
The medicaid
				agency sends hospital safety net program (HSNP) assessment notices on or about
				30 calendar days prior to the end of each quarter as required by
				RCW
				74.60.030 (1)(a).
(2)
Payment due date.
Each
				hospital must pay its assessment in full by the due date listed in the HSNP
				notice.
(3)
First past-due
				notification.
If a hospital does not pay its HSNP assessment in full by
				the due date, the agency sends the hospital a past-due notice. The past-due
				notice informs the hospital of the actions the agency may take if the
				hospital's assessment becomes 60 calendar days past due.
(4)
Final past-due notification.
If a hospital does not pay its assessment in full within 60 calendar days of
				its due date stated in the HSNP notice, the agency sends the hospital a final
				past-due notice.
(a) The final past-due notice
				informs the hospital of the actions the agency takes, as required by
				RCW
				74.60.050(2), to offset
				funds from the agency's scheduled payments to the hospital.
(b) The agency does not offset funds from
				managed care capitation payments, as described in
				RCW
				74.60.130.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-General › Section 182-551-1000 - Hospice program - General

Current through Register Vol. 24-14, July 15, 2024
(1) The
					 medicaid agency's hospice program is a twenty-four hour a day program that
					 allows a terminally ill client to choose physical, pastoral/spiritual, and
					 psychosocial comfort care and a focus on quality of life. A hospice
					 interdisciplinary team communicates with the client's nonhospice care providers
					 to ensure the client's needs are met through the hospice plan of care.
					 Hospitalization is used only for acute symptom management.
(2) A client, a physician, or an authorized
					 representative under
					 RCW
					 7.70.065 may initiate hospice care. The
					 client's physician must certify the client as terminally ill and appropriate
					 for hospice care.
(3) Hospice care
					 is provided in a client's temporary or permanent place of residence.
(4) Hospice care ends when:
(a) The client or an authorized
					 representative under
					 RCW
					 7.70.065 revokes the hospice care;
(b) The hospice agency discharges the
					 client;
(c) The client's physician
					 determines hospice care is no longer appropriate; or
(d) The client dies.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Coverage › Section 182-551-1200 - Client eligibility for hospice care

Current through Register Vol. 24-14, July 15, 2024
(1) A person who elects to receive hospice
					 care must be eligible for one of the Washington apple health programs listed in
					 the table in WAC
					 182-501-0060 or be eligible for
					 the alien emergency medical (AEM) program (see WAC
					 182-507-0110 ), subject to the
					 restrictions and limitations in this chapter and other WAC.
(2) A hospice agency is responsible to verify
					 a person's eligibility with the person or the person's department of social and
					 health services (DSHS) home and community services (HCS) office or community
					 services office (CSO).
(3) A person
					 enrolled in one of the medicaid agency's managed care organizations (MCO) must
					 receive all hospice services, including facility room and board, directly
					 through that MCO. The MCO is responsible for arranging and providing all
					 hospice services for an MCO client.
(4) A person who is also eligible for
					 medicare hospice under part A is not eligible for hospice care through the
					 medicaid agency's hospice program. The medicaid agency does pay hospice nursing
					 facility room and board for these persons if the person is admitted to a
					 nursing facility or hospice care center (HCC) and is not receiving general
					 inpatient care or inpatient respite care. See also WAC
					 182-551-1530.
(5) A person who meets the requirements in
					 this section is eligible to receive hospice care through the medicaid agency's
					 hospice program when all of the following is met:
(a) The person's physician certifies the
					 person has a life expectancy of six months or less.
(b) The person elects to receive hospice care
					 and agrees to the conditions of the "election statement" as described in WAC
					 182-551-1310.
(c) The hospice agency serving the person:
(i) Notifies the medicaid agency's hospice
					 program within five working days of the admission of all persons, including:
(A) Medicaid-only persons;
(B) Medicaid-medicare dual eligible
					 persons;
(C) Medicaid persons with
					 third-party insurance; and
(D)
					 Medicaid-medicare dual eligible persons with third-party insurance.
(ii) Meets the hospice agency
					 requirements in WAC
					 182-551-1300 and
					 182-551-1305.
(d) The hospice agency provides
					 additional information for a diagnosis when the medicaid agency requests and
					 determines, on a case-by-case basis, the information that is needed for further
					 review.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Coverage › Section 182-551-1210 - Covered services, including core services and supplies reimbursed through the hospice daily rate

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
					 agency reimburses a hospice agency for providing covered services, including
					 core services and supplies described in this section, through the medicaid
					 agency's hospice daily rate, subject to the conditions and limitations
					 described in this section and other WAC. See WAC
					 182-551-1860 for pediatric
					 concurrent care.
(2) To qualify for
					 reimbursement, covered services, including core services and supplies in the
					 hospice daily rate, must be:
(a) Related to
					 the client's hospice diagnosis;
(b)
					 Identified by the client's hospice interdisciplinary team;
(c) Written in the client's plan of care
					 (POC); and
(d) Made available to
					 the client by the hospice agency on a twenty-four hour basis.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Provider Requirements › Section 182-551-1300 - Requirements for a medicaid-approved hospice agency

Current through Register Vol. 24-14, July 15, 2024
(1) To become a medicaid-approved hospice
					 agency, the medicaid agency requires a hospice agency to provide documentation
					 that it is medicare, Title XVIII-certified by the department of health (DOH) as
					 a hospice agency.
(2) A
					 medicaid-approved hospice agency must at all times meet the requirements in
					 chapter 182-551 WAC, sub-chapter I, Hospice services, and the requirements
					 under the Title XVIII medicare program.
(3) To ensure quality of care for Washington
					 apple health clients, the medicaid agency's clinical staff may conduct hospice
					 agency site visits.
Statutory Authority:
						  RCW
						  41.05.021, Section 2302 of the Patient
						  Protection and Affordable Care Act of 2010 (
						  P.L.
						  111-148 ), and Section 1814(a)(7) of the Social
						  Security Act. WSR 12-09-079, §
													182-551-1300, filed 4/17/12,
						  effective 5/18/12. WSR 11-14-075, recodified as §
													182-551-1300, filed 6/30/11,
						  effective 7/1/11. Statutory Authority:
						  RCW
						  74.08.090,
						  74.09.520. WSR 05-18-033, §
						  388-551-1300, filed 8/30/05, effective 10/1/05. Statutory Authority:
						  RCW
						  74.09.520,
						  74.08.090,
						  42 C.F.R.
						  418.22 and
						  418.24. WSR 99-09-007, §
						  388-551-1300, filed 4/9/99, effective
						  5/10/99.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Provider Requirements › Section 182-551-1305 - Requirements for becoming a medicaid-approved hospice care center (HCC)

Current through Register Vol. 24-14, July 15, 2024
(1) To apply to
					 become a medicaid-approved hospice care center, the medicaid agency requires a
					 hospice agency to:
(a) Be enrolled with the
					 medicaid agency as an approved hospice agency (see WAC
					 182-551-1300 );
(b) Submit a letter of request to:
Hospice Program Manager
P.O. Box 45506
Olympia, WA 98504-5506; and
(c) Include documentation that confirms the
					 approved hospice agency is medicare certified by department of health (DOH) as
					 a hospice care center and provides one or more of the following levels of
					 hospice care (levels of care are described in WAC
					 182-551-1500 ):
(i) Routine home care;
(ii) Inpatient respite care; and
(iii) General inpatient care.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Provider Requirements › Section 182-551-1310 - Hospice election periods, election statements, and the hospice certification process

Current through Register Vol. 24-14, July 15, 2024
(1) Hospice
					 coverage is available for two ninety-day election periods followed by an
					 unlimited number of sixty-day election periods. A client or a client's
					 authorized representative must sign an election statement to initiate or
					 reinitiate an election period for hospice care.
(2) The election statement must be filed in
					 the client's hospice medical record within two calendar days following the day
					 the hospice care begins and requires all of the following:
(a) Name and address of the hospice agency
					 that will provide the care;
(b)
					 Documentation that the client is fully informed and understands hospice care
					 and waiver of other medicaid and/or medicare services;
(c) Effective date of the election;
					 and
(d) Signature of the client or
					 the client's authorized representative.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Provider Requirements › Section 182-551-1320 - Hospice plan of care

Current through Register Vol. 24-14, July 15, 2024
(1) A hospice
					 agency must establish a written plan of care (POC) for a client that describes
					 the hospice care to be provided. The POC must be in accordance with department
					 of health (DOH) requirements as described in WAC
					 246-335-085, and meet the
					 requirements in this section.
(2) A
					 registered nurse or physician must conduct an initial physical assessment of a
					 client and develop the POC with at least one other member of the hospice
					 interdisciplinary team.
(3) At
					 least two other hospice interdisciplinary team members must review the POC no
					 later than two working days after it is developed.
(4) The POC must be reviewed and updated
					 every two weeks by at least three members of the hospice interdisciplinary team
					 that includes at least:
(a) A registered
					 nurse;
(b) A social worker;
					 and
(c) One other hospice
					 interdisciplinary team member.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Provider Requirements › Section 182-551-1330 - Hospice - Client care and responsibilities of hospice agencies

Current through Register Vol. 24-14, July 15, 2024
(1) A hospice
					 agency must facilitate a client's continuity of care with nonhospice providers
					 to ensure that medically necessary care, both related and not related to the
					 terminal illness, is met. This includes:
(a)
					 Determining if the medicaid agency has approved a request for prescribed
					 medical equipment, such as a wheelchair. If the prescribed item is not
					 delivered to the client before the client becomes covered by a hospice agency,
					 the medicaid agency will rescind the approval. See WAC
					 182-543-9100(7).
(b) Communicating with other medicaid
					 programs and documenting the services a client is receiving in order to prevent
					 duplication of payment and to ensure continuity of care. Other medicaid
					 programs include, but are not limited to, programs administered by the
					 department of social and health services aging and disability services
					 administration (ADSA).
(c)
					 Documenting each contact with nonhospice providers.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Discharges and Notification › Section 182-551-1340 - When a client leaves hospice without notice

Current through Register Vol. 24-14, July 15, 2024
When a client chooses to leave hospice care or refuses
						hospice care without giving the hospice agency a revocation statement, as
						required by WAC
						182-551-1360, the hospice agency
						must do all of the following:
(1)
					 Within five working days of becoming aware of the client's decision, inform and
					 notify in writing the medicaid hospice program manager (see WAC
					 182-551-1400 for further
					 requirements);
(2) Complete a
					 medicaid hospice notification form (HCA 13-746) and forward a copy to the
					 appropriate department of social and health services (DSHS) home and community
					 services (HCS) office or community services office (CSO) to notify that the
					 client is discharging from the program;
(3) Notify the client, or the client's
					 authorized representative, that the client's discharge has been reported to the
					 medicaid agency; and
(4) Document
					 the effective date and details of the discharge in the client's hospice
					 record.
Statutory Authority:
						  RCW
						  41.05.021, Section 2302 of the Patient
						  Protection and Affordable Care Act of 2010 (
						  P.L.
						  111-148 ), and Section 1814(a)(7) of the Social
						  Security Act. WSR 12-09-079, §
													182-551-1340, filed 4/17/12,
						  effective 5/18/12. WSR 11-14-075, recodified as §
													182-551-1340, filed 6/30/11,
						  effective 7/1/11. Statutory Authority:
						  RCW
						  74.08.090,
						  74.09.520. WSR 05-18-033, §
						  388-551-1340, filed 8/30/05, effective 10/1/05. Statutory Authority:
						  RCW
						  74.09.520,
						  74.08.090,
						  42 C.F.R.
						  418.22 and
						  418.24. WSR 99-09-007, §
						  388-551-1340, filed 4/9/99, effective
						  5/10/99.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Discharges and Notification › Section 182-551-1350 - Discharges from hospice care

Current through Register Vol. 24-14, July 15, 2024
(1) A
					 hospice agency may discharge a client from hospice care when the client:
(a) Is no longer certified for hospice
					 care;
(b) Is no longer appropriate
					 for hospice care; or
(c) The
					 hospice agency's medical director determines the client is seeking treatment
					 for the terminal illness outside the plan of care (POC).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Discharges and Notification › Section 182-551-1360 - Ending hospice care (revocations)

Current through Register Vol. 24-14, July 15, 2024
(1) A client or a client's authorized
					 representative may choose to stop hospice care at any time by signing a
					 revocation statement.
(2) The
					 revocation statement documents the client's choice to stop medicaid hospice
					 care. The revocation statement must include all of the following:
(a) Client's signature (or the client's
					 authorized representative's signature if the client is unable to
					 sign);
(b) Date the revocation was
					 signed; and
(c) Actual date that
					 the client chose to stop receiving hospice care.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Discharges and Notification › Section 182-551-1370 - When a hospice client dies

Current through Register Vol. 24-14, July 15, 2024
When a client dies, the hospice agency must:
(1) Within five working days, inform and
					 notify in writing the medicaid agency's hospice program manager; and
(2) Notify the appropriate department of
					 social and health services (DSHS) home and community services (HCS) office or
					 community services office (CSO) of the client's date of death by completing and
					 forwarding a copy of the medicaid hospice notification form (HCA 13-746) to the
					 appropriate DSHS HCS office or CSO.
Statutory Authority:
						  RCW
						  41.05.021, Section 2302 of the Patient
						  Protection and Affordable Care Act of 2010 (
						  P.L.
						  111-148 ), and Section 1814(a)(7) of the Social
						  Security Act. 12-09-079, §
													182-551-1370, filed 4/17/12,
						  effective 5/18/12. 11-14-075, recodified as §
													182-551-1370, filed 6/30/11,
						  effective 7/1/11. Statutory Authority:
						  RCW
						  74.08.090,
						  74.09.520. 05-18-033, §
						  388-551-1370, filed 8/30/05, effective
						  10/1/05.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Discharges and Notification › Section 182-551-1400 - Notification requirements for hospice agencies

Current through Register Vol. 24-14, July 15, 2024
(1) To be reimbursed for providing hospice
					 services, the hospice agency must complete a medicaid hospice notification form
					 (HCA 13-746) and forward the form to the medicaid agency's hospice program
					 manager within five working days from when a Washington apple health client
					 begins the first day of hospice care, or has a change in hospice status. The
					 hospice agency must notify the medicaid hospice program of:
(a) The name and address of the hospice
					 agency;
(b) The date of the
					 client's first day of hospice care;
(c) A change in the client's primary
					 physician;
(d) A client's
					 revocation of the hospice benefit (home or institutional);
(e) The date a client leaves hospice without
					 notice;
(f) A client's discharge
					 from hospice care;
(g) A client who
					 admits to a nursing facility (this does not apply to an admit for inpatient
					 respite care or general inpatient care);
(h) A client who discharges from a nursing
					 facility (this does not apply to an admit for inpatient respite care or general
					 inpatient care;
(i) A client who is
					 eligible for or becomes eligible for medicare or third-party liability (TPL)
					 insurance;
(j) A client who dies;
					 or
(k) A client who transfers to
					 another hospice agency. Both the former hospice agency and current hospice
					 agency must provide the medicaid agency with:
(i) The client's name, the name of the former
					 hospice agency servicing the client, and the effective date of the client's
					 discharge; and
(ii) The name of the
					 current hospice agency serving the client, the hospice agency's provider
					 number, and the effective date of the client's admission.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1500 - Hospice daily rate-Four levels of hospice care

Current through Register Vol. 24-14, July 15, 2024
All services, supplies and equipment related to the
						client's terminal illness and related conditions are included in the hospice
						daily rate. The medicaid agency pays for only one of the following four levels
						of hospice care per day (see WAC
						182-551-1510 for payment
						methods):
(1)
Routine home
					 care.
Routine home care includes daily care administered to the client
					 at the client's residence. The services are not restricted in length or
					 frequency of visits, are dependent on the client's needs, and are provided to
					 achieve palliation or management of acute symptoms.
(2)
Continuous home care.
Continuous home care includes acute skilled care provided to an unstable client
					 during a brief period of medical crisis to maintain the client in the client's
					 residence and is limited to:
(a) A minimum of
					 eight hours of acute care provided during a twenty-four-hour day;
(b) Nursing care that must be provided by a
					 registered or licensed practical nurse for more than half the period of
					 care;
(c) Homemaker, hospice aide,
					 and attendant services that may be provided as supplements to the nursing care;
					 and
(d) In home care only (not care
					 in a nursing facility or a hospice care center).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1510 - Rates methodology and payment method for hospice agencies

Current through Register Vol. 24-14, July 15, 2024
This section describes rates methodology and payment
						methods for hospice care provided to hospice clients.
(1) The medicaid agency uses the same rates
					 methodology as medicare uses for the four levels of hospice care identified in
					 WAC 182-551-1500.
(2) Each of the four levels of hospice care
					 has the following three rate components:
(a)
					 Wage component;
(b) Wage index;
					 and
(c) Unweighted
					 amount.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1520 - Payment method for nonhospice providers

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for hospitals
					 that provide inpatient care to clients in the hospice program for medical
					 conditions not related to their terminal illness according to chapter 182-550
					 WAC, Hospital services.
(2) The
					 medicaid agency pays providers who are attending physicians and not employed by
					 the hospice agency, the usual amount through the resource based relative value
					 scale (RBRVS) fee schedule:
(a) For direct
					 physician care services provided to a hospice client;
(b) When the provided services are not
					 related to the terminal illness; and
(c) When the client's providers, including
					 the hospice agency, coordinate the health care provided.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1530 - Payment method for medicaid-medicare dual eligible clients

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
					 agency will not pay the portion of hospice care for a client that is covered
					 under medicare part A. Nursing home room and board charges described in WAC
					 182-551-1510 that are not covered
					 under medicare part A may be covered by the medicaid agency.
(2) The medicaid agency may pay for hospice
					 care provided to a client:
(a) Covered by
					 medicaid part B (medical insurance); and
(b) Not covered by medicare part A.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1800 - Pediatric palliative care (PPC) case management/coordination services - General

Current through Register Vol. 24-14, July 15, 2024
Through a hospice agency, the medicaid agency's pediatric
						palliative care (PPC) case management/coordination services provide the care
						coordination and skilled care services to clients who have life-limiting
						medical conditions. Family members and caregivers of clients eligible for
						pediatric palliative care services may also receive support through care
						coordination when the services are related to the client's medical
						needs.
Statutory Authority:
						  RCW
						  41.05.021, Section 2302 of the Patient
						  Protection and Affordable Care Act of 2010 (
						  P.L.
						  111-148 ), and Section 1814(a)(7) of the Social
						  Security Act. 12-09-079, §
													182-551-1800, filed 4/17/12,
						  effective 5/18/12. 11-14-075, recodified as §
													182-551-1800, filed 6/30/11,
						  effective 7/1/11. Statutory Authority:
						  RCW
						  74.08.090,
						  74.09.520. 05-18-033, §
						  388-551-1800, filed 8/30/05, effective
						  10/1/05.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1810 - Pediatric palliative care (PPC) case management/coordination services - Client eligibility

Current through Register Vol. 24-14, July 15, 2024
To receive pediatric palliative care (PPC) case
						management/coordination services, a person must:
(1) Be twenty years of age or
					 younger;
(2) Be a current recipient
					 of the:
(a) Categorically needy program
					 (CNP);
(b) Limited casualty program
					 - Medically needy program (LCP-MNP);
(c) CNP - Alien emergency medical;
(d) LCP-MNP - Alien emergency
					 medical;
(e) Children's health
					 insurance program (SCHIP); and
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1820 - Pediatric palliative care (PPC) contact - Services included and limitations to coverage

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
					 agency's pediatric palliative care (PPC) case management/coordination services
					 cover up to six pediatric palliative care contacts per client, per calendar
					 month, subject to the limitations in this section and other applicable
					 WAC.
(2) One pediatric palliative
					 care contact consists of:
(a) One visit with
					 a registered nurse, social worker, or therapist (for the purpose of this
					 section, the medicaid agency defines therapist as a licensed physical
					 therapist, occupational therapist, or speech/language therapist) with the
					 client in the client's residence to address:
(i) Pain and symptom management;
(ii) Psychosocial counseling; or
(iii) Education/training.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1830 - How to become a medicaid-approved pediatric palliative care (PPC) case management/coordination services provider

Current through Register Vol. 24-14, July 15, 2024
This section applies to medicaid-approved providers who
						currently do not provide pediatric palliative care (PPC) services to medical
						assistance clients.
(1) To apply to
					 become a medicaid-approved provider of PPC services, a provider must:
(a) Be a medicaid-approved hospice agency
					 (see WAC 182-551-1300 and
					 182-551-1305 ); and
(b) Submit a letter to the medicaid agency's
					 hospice/PPC program manager requesting to become a medicaid-approved provider
					 of PPC and include a copy of the provider's policies and position descriptions
					 with minimum qualifications specific to pediatric palliative care.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1850 - Pediatric palliative care (PPC) case management/coordination services-Rates methodology

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
					 agency determines the reimbursement rate for a pediatric palliative care (PPC)
					 contact described in WAC
					 182-551-1820 using the average of
					 statewide metropolitan statistical area (MSA) home health care rates for
					 skilled nursing, physical therapy, speech language therapy and occupational
					 therapy.
(2) The medicaid agency
					 makes adjustments to the reimbursement rate for PPC contacts when the
					 legislature grants a vendor rate change. New rates become effective as directed
					 by the legislature and are effective until the next rate change.
(3) The reimbursement rate for authorized
					 out-of-state PPC services is the same as the in-state non-MSA rate.
11-14-075, recodified as §
													182-551-1850, filed 6/30/11,
						  effective 7/1/11. Statutory Authority:
						  RCW
						  74.08.090,
						  74.09.520. 05-18-033, §
						  388-551-1850, filed 8/30/05, effective
						  10/1/05.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter I - HOSPICE SERVICES › Hospice-Payment › Section 182-551-1860 - Concurrent care for hospice clients age twenty and younger

Current through Register Vol. 24-14, July 15, 2024
(1) In accordance
					 with 42 U.S.C.
					 1396d(o)(1)(C), a client age
					 twenty and younger may voluntarily elect hospice care without waiving any
					 rights to services that the client is entitled to under Title XIX Medicaid and
					 Title XXI Children's Health Insurance Program (CHIP) that are related to the
					 treatment of the client's condition for which a diagnosis of terminal illness
					 has been made.
(2) The related
					 services in subsection (1) of this section and medications requested for
					 clients age twenty and younger are subject to the medicaid agency's specific
					 program rules governing those services or medications.
(3) When a noncovered service is recommended
					 based on the early and periodic screening, diagnosis, and treatment (EPSDT)
					 program, the agency evaluates the request for medical necessity based on the
					 definition in WAC
					 182-500-0070
					 and the process in WAC
					 182-501-0165.
(4) If the medicaid agency denies a request
					 for a covered service, refer to WAC
					 182-502-0160,
					 billing a client, for when a client may be responsible to pay for a covered
					 service.
Statutory Authority:
						  RCW
						  41.05.021, Section 2302 of the Patient
						  Protection and Affordable Care Act of 2010 (
						  P.L.
						  111-148 ), and Section 1814(a)(7) of the Social
						  Security Act. 12-09-079, §
													182-551-1860, filed 4/17/12,
						  effective 5/18/12.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2000 - General

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
				  the medicaid agency's home health services program is to reduce the costs of
				  health care services by providing equally effective, less restrictive quality
				  care to the client in any setting where normal life activities take place,
				  subject to the restrictions and limitations in subchapter II. See also
				  42 C.F.R.
				  440.70.
(2) Home health services include the
				  following services and items:
(a) Nursing
				  services, see WAC
				  182-551-2100;
(b) Home health aide service, see WAC
				  182-551-2120;
(c) Medical supplies, equipment, and
				  appliances suitable for use in any setting where normal life activities take
				  place, see chapter 182-543 WAC;
(d)
				  Physical therapy, occupational therapy, or speech therapy, see WAC
				  182-551-2110, and audiology
				  services, see WAC
				  182-531-0375; and
(e) Medical social services, see WAC
				  182-551-2115.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2020 - Eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) Washington
				  apple health clients are eligible for home health services as identified in the
				  table in WAC
				  182-501-0060 and subject to the
				  provisions in this chapter.
(2)
				  Clients enrolled in an agency-contracted managed care organization (MCO)
				  receive all home health services through their designated plan. EVV
				  requirements are applicable to the in-home delivery of home health services for
				  clients enrolled in a managed care organization.
(3) The agency covers home health services
				  for clients in the alien emergency medical program under WAC
				  182-507-0120.
11-14-075, recodified as §
												182-551-2020, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090, chapter 74.09 RCW, and 2009 c 326.
						10-10-087, § 388-551-2020, filed 5/3/10, effective 6/3/10. Statutory
						Authority:
						RCW
						74.08.090,
						74.09.520,
						74.09.530, and
						74.09.500. 02-15-082, §
						388-551-2020, filed 7/15/02, effective 8/15/02. Statutory Authority:
						RCW
						74.08.090 and
						74.09.530. 99-16-069, §
						388-551-2020, filed 8/2/99, effective
						9/2/99.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2030 - Skilled services-Requirements

Current through Register Vol. 24-14, July 15, 2024
(1) The medic-aid
				  agency covers home health skilled services provided to eligible clients,
				  subject to the provisions in this section and other applicable published
				  WAC.
(2) Home health skilled
				  services provided to eligible clients must:
(a) Meet the definition of "acute care" in
				  WAC 182-551-2010;
(b) Provide for the treatment of an illness,
				  injury, or disability;
(c) Be
				  medically necessary as defined in WAC
				  182-500-0070 and the process
				  outlined in WAC
				  182-501-0165;
(d) Be reasonable, based on the community
				  standard of care, in amount, duration, and frequency;
(e) Meet face-to-face requirements described
				  in WAC 182-551-2040;
(f) Be provided under a plan of care (POC),
				  as defined in WAC
				  182-551-2010 and described in WAC
				  182-551-2210. Any statement in
				  the POC must be supported by documentation in the client's medical
				  records;
(g) Be used to prevent
				  placement in a more restrictive setting;
(h) Be provided in any setting where normal
				  life activities take place; and
(i)
				  The client's medical records must justify the medical reason or reasons that
				  the services should be provided where the client's normal life activities take
				  place instead of at an ordering physician's office, clinic, or other outpatient
				  setting.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2040 - Face-to-face encounter requirements

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency pays for home health services provided under this chapter only when the
				  face-to-face encounter requirements in this section are met.
(2) The face-to-face encounter requirements
				  of this section may be met using telemedicine services. See WAC
				  182-551-2125.
(3) For initiation of home health services,
				  with the exception of medical equipment under WAC
				  182-551-2122, the face-to-face
				  encounter must be related to the primary reason the client requires home health
				  services and must occur within 90 calendar days before or within the 30
				  calendar days after the start of the home health services.
(4) For the initiation of medical equipment
				  under WAC
				  182-551-2122, the face-to-face
				  encounter must be related to the primary reason the client requires medical
				  equipment and must occur no more than six months before the start of
				  services.
(5) The face-to-face
				  encounter may be conducted by:
(a) A
				  physician;
(b) A nurse
				  practitioner;
(c) A clinical nurse
				  specialist;
(d) 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;
(e) A physician assistant; or
(f) The attending acute, or post-acute
				  physician, for beneficiaries admitted to home health immediately after an acute
				  or post-acute stay.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2100 - Skilled nursing services

Current through Register Vol. 24-14, July 15, 2024
(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.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2110 - Specialized therapy

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers outpatient rehabilitation and habilitative services only when
				  provided:
(a) By a home health agency;
				  and
(b) In any setting where normal
				  life activities take place.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2115 - Medical social services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers medical social services under program rules, including the rules
				  in this chapter.
(2) Medical social
				  services include the following:
(a) Assessment
				  of the social and emotional factors related to the client's illness;
(b) Need for care, response to treatment, and
				  adjustment to care;
(c) Evaluation
				  of the client's home situation, financial resources, and availability of
				  community resources;
(d) Assistance
				  in obtaining available community resources and financial resources;
				  and
(e) Counseling the client and
				  family to address emotional issues related to the illness.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2120 - Aide services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers home health aide services.
(2) The agency pays for one visit per client,
				  per day under program rules, including the rules in this chapter.
(3) The medicaid agency may authorize
				  additional services on a case-by-case basis under WAC
				  182-501-0169.
11-14-075, recodified as §
												182-551-2120, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090, chapter 74.09 RCW, and 2009 c 326.
						10-10-087, § 388-551-2120, filed 5/3/10, effective 6/3/10. Statutory
						Authority:
						RCW
						74.08.090,
						74.09.520,
						74.09.530, and
						74.09.500. 02-15-082, §
						388-551-2120, filed 7/15/02, effective 8/15/02. Statutory Authority:
						RCW
						74.08.090 and
						74.09.530. 99-16-069, §
						388-551-2120, filed 8/2/99, effective
						9/2/99.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2122 - Medical supplies, equipment, and appliances

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency covers medical supplies, equipment, and
					 appliances, as defined and described in chapter 182-543 WAC.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2125 - Home health services delivered using telemedicine

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency pays for the delivery of one home health service through telemedicine,
				  per eligible client, per day, under WAC
				  182-501-0300 and the requirements
				  in this section.
(2) For clients to
				  be eligible to receive home health services through telemedicine, the medicaid
				  agency requires the client to:
(a) Be
				  diagnosed with an unstable condition causing the client to be at risk for
				  hospitalization or a more costly level of care; and
(b) Have a diagnosis or diagnoses where there
				  is a high risk of sudden change in clinical status which could compromise
				  health outcomes.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2130 - Noncovered services

Current through Register Vol. 24-14, July 15, 2024
(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).
(i) Prior to
				  ALTSA 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.