reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2200 - Eligible providers

Current through Register Vol. 24-14, July 15, 2024
The following may contract with the medicaid agency to
					 provide home health services through the home health program, subject to the
					 requirements and limitations in this section and other applicable published
					 WAC:
(1) A home health agency that:
(a) Is Title XVIII (medicare)-certified, or
				  if the services being provided are not covered by medicare, the provider may
				  attest to the medicaid agency it meets the requirements for participation in
				  medicare;
(b) Is licensed by the
				  department of health (DOH) as a home health agency;
(c) Submits a completed, signed core provider
				  agreement to the medicaid agency and is enrolled; and
(d) Has a home health taxonomy on their
				  provider file in the medicaid agency's claim payment system.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2210 - Provider requirements

Current through Register Vol. 24-14, July 15, 2024
(1) For any home
				  health services to be payable, the medicaid agency requires home health
				  providers to develop and implement an individualized plan of care (POC) for the
				  client that must:
(a) Be documented in
				  writing and be located in the client's home health medical record;
(b) Be developed, supervised, and signed by a
				  licensed registered nurse or licensed therapist;
(c) Reflect the authorized practitioner's
				  orders and client's current health status;
(d) Contain specific goals and treatment
				  plans;
(e) Be reviewed and revised
				  by an authorized practitioner at least every 60 calendar days;
(f) Be signed by the authorized practitioner
				  within 45 days if a verbal order is given; and
(g) Be available to medicaid agency staff or
				  its designated contractor(s) on request.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-2220 - Provider payments

Current through Register Vol. 24-14, July 15, 2024
(1) To be
				  reimbursed, the home health provider must bill the medicaid agency according to
				  medicaid program rules, including chapter 182-502 WAC and agency published
				  billing instructions.
(2) Payment
				  to home health providers is:
(a) A set rate
				  per visit for each discipline provided to a client;
(b) Based on the county location of the
				  providing home health agency; and
(c) Updated by general vendor rate
				  changes.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-3000 - Private duty nursing for clients age seventeen and younger- General

Current through Register Vol. 24-14, July 15, 2024
(1) The medically
				  intensive children's program (MICP) provides private duty nursing to clients,
				  either through fee-for-service or an agency-contracted managed care
				  organization (MCO).
(2) The MICP is
				  available to clients age seventeen and younger, whose complex medical needs
				  cannot be managed within the scope of intermittent home health
				  services.
(3) Managed care clients
				  receive private duty nursing services through their agency-contracted MCO. (See
				  chapter 182-538 WAC). Providers must follow the policies and procedures of the
				  client's MCO, including the authorization of services.
(4) For clients with third-party liability
				  (TPL) coverage (see WAC
				  182-500-0105
				  ) that includes private duty nursing, the procedures and policies in subchapter
				  III, titled Private Duty Nursing, apply when determining coverage of additional
				  hours under MICP.
11-14-075, recodified as §
												182-551-3000, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.04.050,
						74.08.090,
						74.09.530, and
						74.09.700. 06-24-036, §
						388-551-3000, filed 11/30/06, effective 1/1/07. Statutory Authority:
						RCW
						74.08.090 and
						74.09.520. 01-05-040, §
						388-551-3000, filed 2/14/01, effective
						3/17/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-3050 - Private duty nursing for clients age seventeen and younger-Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions and those found in chapter
					 182-500 WAC apply to this subchapter.
"Nursing care consultant"
means a registered
					 nurse employed by the department of social and health services (DSHS) to
					 evaluate clinical eligibility for the medically intensive children's program
					 (MICP) and provide a written assessment summary.
"Private duty nursing"
means skilled nursing
					 care and services provided in the home for clients with complex medical needs
					 that cannot be managed within the scope of intermittent home health
					 services.
"Skilled nursing care"
means the medical care
					 provided by a licensed nurse or delegate working under the direction of a
					 physician as described in
					 RCW
					 18.79.260.
"Skilled nursing services"
means the
					 management and administration of skilled nursing care requiring the specialized
					 judgment, knowledge, and skills of a registered nurse or licensed practical
					 nurse as described in
					 RCW
					 18.79.040 and
					 18.79.060.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-3100 - Private duty nursing for clients age seventeen and younger-Client eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) To be
				  eligible for private duty nursing under the medically intensive children's
				  program (MICP), clients must:
(a) Be age
				  seventeen or younger;
(b) Meet
				  financial eligibility under subsection (2) of this section;
(c) Meet medical eligibility under subsection
				  (3) of this section;
(d) Have
				  informal support by a person who has been trained to provide designated skilled
				  nursing care and is able to perform the care as required;
(e) Have prior authorization from the
				  department of social and health services/developmental disabilities
				  administration (DSHS/DDA); and
(f)
				  Have exhausted all other funding sources for private duty nursing, according to
				  RCW
				  74.09.185, prior to accessing these services
				  through the medically intensive children's program (MICP).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-3200 - Private duty nursing for clients age seventeen and younger-Provider requirements

Current through Register Vol. 24-14, July 15, 2024
Providers qualified to deliver private duty nursing under
					 the medically intensive children's program must have the following:
(1) An in-home services license with the
				  state of Washington to provide private duty nursing;
(2) A contract with the department of social
				  and health services/developmental disabilities administration (DSHS/DDA) to
				  provide private duty nursing; and
(3) A signed core provider agreement with the
				  medicaid agency.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-3300 - Private duty nursing for clients age seventeen and younger-Application requirements

Current through Register Vol. 24-14, July 15, 2024
Clients requesting private duty nursing through
					 fee-for-service must submit a complete signed medically intensive children's
					 program (MICP) application (DSHS form 15-398). The MICP application must
					 include the following:
(1) DSHS 14-012
				  consent form;
(2) DSHS 14-151
				  request for DDA eligibility determination form for clients not already
				  determined DDA eligible;
(3) DSHS
				  03-387 notice of practices for client medical information;
(4) Appropriate and current medical
				  documentation including medical plan of treatment or plan of care (WAC
				  246-335-080
				  ) with the client's age, medical history, diagnoses, and the parent/guardian
				  contact information including address and phone number;
(5) A list of current treatments or treatment
				  records;
(6) Information about
				  ventilator, bilevel positive airway pressure (BiPAP), or continuous positive
				  airway pressure (CPAP) hours per day or frequency of use;
(7) History and physical from current
				  hospital admission, recent discharge summary, or recent primary physician
				  exam;
(8) A recent interim summary,
				  discharge summary, or clinical summary;
(9) Recent nursing charting within the past
				  five to seven days of hospitalization or in-home nursing
				  documentation;
(10) Current nursing
				  care plan that may include copies of current daily nursing notes that describe
				  nursing care activities;
(11) An
				  emergency medical plan that includes strategies to address loss of power and
				  environmental disasters such as methods to maintain life-saving medical
				  equipment supporting the client. The plan may include notification of electric
				  and gas companies and the local fire department;
(12) A psycho-social history/summary with the
				  following information, as available:
(a)
				  Family arrangement and current situation;
(b) Available personal support systems;
				  and
(c) Presence of other stresses
				  within and upon the family.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-551 - Alternatives to hospital services › Subchapter II - HOME HEALTH SERVICES › Section 182-551-3400 - Private duty nursing for clients age seventeen and younger-Authorization

Current through Register Vol. 24-14, July 15, 2024
(1)
				  Private duty nursing when provided through fee-for-service requires prior
				  authorization from the department of social and health services/developmental
				  disabilities administration (DSHS/ DDA).
(2) DSHS/DDA authorizes requests for private
				  duty nursing on a case-by-case basis when:
(a) The application requirements under WAC
				  182-551-3300 are met; and
(b) The
				  nursing care consultant determines the services to be medically necessary, as
				  defined in WAC
				  182-500-0070
				  and according to the process in WAC
				  182-501-0165.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › Section 182-552-0001 - Respiratory care-General

Current through Register Vol. 24-14, July 15, 2024
(1) The
				respiratory care, equipment, and supplies described in this chapter applies to:
(a) Medicaid clients who require respiratory
				care in their homes, community residential settings, and skilled nursing
				facilities;
(b) Providers who
				supply respiratory care to medicaid clients; and
(c) Licensed health care professionals whose
				scope of practice allows for the provision of respiratory care.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › CLIENT ELIGIBILITY › Section 182-552-0100 - Respiratory care - Client eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) To receive respiratory care, a person
				  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 (as described in WAC
				  182-507-0110 ).
(2) Persons who are enrolled in an
				  agency-contracted managed care organization (MCO) must arrange for all
				  respiratory care directly through his or her MCO.
(3) For persons residing in skilled nursing
				  facilities, boarding homes, and adult family homes, see WAC
				  182-552-0150.
(4) Persons who are eligible for services
				  under medicare and medicaid (medically needy program-qualified medicare
				  beneficiaries) are eligible for respiratory care.
Statutory Authority:
						RCW
						41.05.021. 12-14-022, §
												182-552-0100, filed 6/25/12,
						effective 8/1/12.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › CLIENT ELIGIBILITY › Section 182-552-0150 - Respiratory care - Clients residing in skilled nursing facilities, boarding homes, and adult family homes

Current through Register Vol. 24-14, July 15, 2024
For eligible clients who reside in skilled nursing
					 facilities, boarding homes, and adult family homes:
(1) The medicaid agency pays, according to
				  the requirements in this chapter, for the chronic use of medically necessary
				  respiratory care.
(2) The medicaid
				  agency does not pay separately for the following:
(a) Emergency oxygen equipment and supplies;
				  and
(b) Licensed respiratory care
				  staff.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › PROVIDERS › Section 182-552-0200 - Respiratory care-Provider requirements

Current through Register Vol. 24-14, July 15, 2024
(1) To receive payment for respiratory care
				  equipment and supplies under this chapter, a provider must:
(a) Meet the general provider requirements in
				  chapter 182-502 WAC;
(b) Obtain
				  prior authorization from the medicaid agency, if required, before delivery to
				  the client and before billing the agency;
(c) Keep initial and subsequent prescriptions
				  according to the requirements within this chapter;
(d) Provide instructions to the client and/or
				  caregiver on the safe and proper use of equipment provided;
(e) Have a licensed health care professional
				  whose scope of practice allows for the provision of respiratory care. The
				  licensed health care professional must also:
(i) Check equipment and ensure equipment
				  settings continue to meet the client's needs; and
(ii) Communicate with the client's authorized
				  prescriber if there are any concerns or recommendations.
(f) Verify that the client has a valid
				  prescription.
(i) To be valid, a prescription
				  must:
(A) Be written, and signed and dated by
				  a physician, advanced registered nurse practitioner (ARNP), or physician's
				  assistant certified (PAC); and
(B)
				  State the specific items or services requested, including the quantity,
				  frequency, and duration/length of need. Prescriptions that only state"as
				  needed" or "PRN" are not sufficient; and
(C) For an initial prescription, not be older
				  than three months from the date the prescriber signed the prescription;
				  or
(D) For subsequent
				  prescriptions, not be older than one year from the date the initial
				  prescription was signed. (See WAC
				  182-552-0800 for
				  exceptions.)
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › PROVIDERS › Section 182-552-0250 - Respiratory care - Proof of delivery

Current through Register Vol. 24-14, July 15, 2024
(1)
				  When a provider delivers equipment directly to the client or the client's
				  authorized representative, the provider must furnish the proof of delivery when
				  the medicaid agency requests that information.
(2) The medicaid agency requires the proof of
				  delivery to:
(a) Be signed and dated by the
				  client or the client's authorized representative (the date of signature must be
				  the date the item was received by the client); and
(b) Include the client's name and a detailed
				  description of the item(s) delivered, including the quantity, brand name, and
				  serial number.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › APNEA MONITORS › Section 182-552-0300 - Respiratory care - Covered - Apnea monitors and supplies

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency covers, without prior
				  authorization, the rental of an apnea monitor (cardiorespiratory monitor) with
				  recording feature for a maximum of six months when:
(a) The client is less than one year of age
				  and meets at least one of the following clinical criteria:
(i) Born less than thirty-seven weeks
				  gestation, and the infant is not more than forty-three weeks corrected
				  gestational age;
(ii) Had an
				  apparent life-threatening apneic event (defined as requiring mouth-to-mouth
				  resuscitation or vigorous stimulation);
(iii) Has been diagnosed with bradycardia and
				  is being treated with caffeine, theophylline, or other stimulating
				  agents;
(iv) Has documented
				  gastro-esophageal reflux which results in apnea, bradycardia, or oxygen
				  desaturation;
(v) Has documented
				  apnea greater than twenty seconds in duration;
(vi) Has apnea for periods less than twenty
				  seconds in duration and accompanied by bradycardia, cyanosis, or
				  pallor;
(vii) Has bradycardia
				  (defined as heart rate less than one hundred beats per minute);
(viii) Has oxygen desaturation below ninety
				  percent;
(ix) Has
				  neurologic/anatomic/metabolic or respiratory diseases affecting respiratory
				  drive; or
(x) Is a subsequent
				  sibling of an infant who died of sudden infant death syndrome (SIDS), until the
				  client is one month older than the age at which the earlier sibling died and
				  the client remains event-free; and
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › CPAP/BI-LEVEL RAD › Section 182-552-0400 - Respiratory care-Continuous positive airway pressure (CPAP) device and supplies

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers, without prior authorization, one continuous positive airway
				  pressure (CPAP) device including related supplies, per client, every five
				  years. The CPAP device must have a data card and the client must meet the
				  following clinical criteria:
(a)The client is
				  diagnosed with obstructive sleep apnea (OSA) using a clinical evaluation and a
				  positive attended polysomnogram (PSG) performed in a sleep laboratory or an
				  unattended home sleep test; and
(b)For clients age twenty-one and older:
(i) The client's polysomnogram or home sleep
				  test demonstrates an apnea-hypopnea index (AHI) or respiratory disturbance
				  index (RDI) greater than or equal to fifteen events per hour ; or
(ii) The client's polysomnogram or home sleep
				  test demonstrates the AHI or RDI is greater than or equal to five and less than
				  or equal to fourteen events per hour with clinical documentation of:
(A) Excessive daytime sleepiness, impaired
				  cognition, mood disorders, or insomnia; or
(B) Hypertension, ischemic heart disease, or
				  history of stroke.
(c) For clients age twenty and younger, the
				  clinical criteria is considered met when there is a documented diagnosis of OSA
				  and polysomnography demonstrates an apnea index (AI) or AHI equal to or greater
				  than one and:
(i) Adenotonsillectomy has been
				  unsuccessful in relieving OSA; or
(ii) Adenotonsillar tissue is minimal;
				  or
(iii) Adenotonsillectomy is
				  inappropriate based on OSA being attributable to another underlying cause
				  (e.g., craniofacial anomaly, obesity) or adenotonsillectomy is contraindicated;
				  or
(iv) Family does not wish to
				  pursue surgical intervention.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › CPAP/BI-LEVEL RAD › Section 182-552-0450 - Mandibular advancement device

Current through Register Vol. 24-14, July 15, 2024
The agency covers the purchase of a mandibular advancement
					 device for a client when the provider determines that the use of a continuous
					 positive airway pressure (CPAP) device is medically contraindicated or the
					 client cannot medically tolerate a CPAP device. Prior authorization is required
					 for all eligible clients.
(1) The
				  agency considers a mandibular advancement device to be medical equipment
				  subject to the same billing requirements, restrictions, and limitations as
				  other medical equipment according to chapter 182-543 WAC.
(2) For clients:
(a) Who have natural dentition, the agency
				  pays for one custom-made mandibular advancement device every five years. The
				  client must:
(i) Complete a face-to-face
				  evaluation with a sleep medicine physician in an agency-designated center of
				  excellence (COE) prior to sleep testing;
(ii) Be diagnosed with obstructive sleep
				  apnea (OSA) using a clinical evaluation and positive attended polysomnogram
				  (PSG); and
(iii) Meet the sleep
				  testing criteria described in WAC
				  182-552-0400.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › CPAP/BI-LEVEL RAD › Section 182-552-0500 - Respiratory care - Covered - Bi-level respiratory assist devices and supplies

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers, without prior authorization, one bi-level respiratory assist
				  device (RAD), with or without a back-up rate feature, per client every five
				  years. The client must have a clinical disorder characterized as one of the
				  following and meet the clinical criteria for the specific condition as listed
				  in subsections (2) through (5) of this section.
(a) Restrictive thoracic disorders (e.g.,
				  neuromuscular diseases or severe thoracic cage abnormalities); or
(b) Severe chronic obstructive pulmonary
				  disease (COPD); or
(c) Central
				  sleep apnea or complex sleep apnea; or
(d) Hypoventilation syndrome.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › AIRWAY CLEARANCE DEVICES › Section 182-552-0600 - Respiratory care - Covered - Airway clearance devices

Current through Register Vol. 24-14, July 15, 2024
Chest physiotherapy (CPT), which is also known as
					 percussion and postural drainage (P/PD), is traditionally seen as the standard
					 of care of secretion clearance methods. There are client instances when
					 conventional manual CPT is unavailable, ineffective, or not tolerated. The
					 medicaid agency then covers the following types of airway clearance devices
					 when medically necessary for an individual with a diagnosis that is
					 characterized by excessive mucus production and difficulty clearing
					 secretions:
(1) Mechanical percussors.
				  One per client, per lifetime;
(2)
				  Oscillatory positive expiratory pressure devices. One per client every one
				  hundred and eighty days;
(3)
				  Positive expiratory pressure devices. Requires prior authorization
				  (PA);
(4) Cough stimulating device,
				  alternating positive and negative airway pressure. Requires PA; and
(5) High frequency chest wall oscillation
				  air-pulse generator system. Requires PA.
Statutory Authority:
						RCW
						41.05.021. 12-14-022, §
												182-552-0600, filed 6/25/12,
						effective 8/1/12.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › NEBULIZERS/HUMIDIFIERS/INHALATION DRUGS › Section 182-552-0650 - Respiratory care - Covered - Nebulizers, humidifiers, and accessories

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers, without prior authorization, the purchase of a nebulizer and
				  related compressor, with limits, when the following medicare clinical criteria
				  are met.
(a) Small volume nebulizer and
				  related compressor for the administration of inhalation drugs for:
(i) The management of obstructive pulmonary
				  disease;
(ii) A client with cystic
				  fibrosis or bronchiectasis;
(iii) A
				  client with HIV, pneumocystosis, or complications of organ transplants;
				  or
(iv) Persistent, thick, or
				  tenacious pulmonary secretions.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › NEBULIZERS/HUMIDIFIERS/INHALATION DRUGS › Section 182-552-0700 - Respiratory care - Covered - Inhalation drugs and solutions

Current through Register Vol. 24-14, July 15, 2024
Inhalation drugs and solutions are included in the medicaid
					 agency's prescription drug program. Refer to chapter 182-530
					 WAC.
Statutory Authority:
						RCW
						41.05.021. 12-14-022, §
												182-552-0700, filed 6/25/12,
						effective 8/1/12.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › OXYGEN AND OXYGEN EQUIPMENT › Section 182-552-0800 - Respiratory care-Covered-Oxygen and oxygen equipment

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency covers oxygen and
				  oxygen equipment as provided in this chapter.
(2) The agency pays for the rental of a
				  stationary oxygen system and/or a portable oxygen system, as follows:
(a) For clients, age 20 and younger, when
				  prescribed by the client's treating practitioner; or
(b) For clients, age 21 and older, when
				  prescribed by a practitioner and the client meets:
(i) Medicare's Group I or Group II clinical
				  criteria; or
(ii) The Group III
				  clinical criteria described in WAC
				  182-552-0005.
(c) If a client age 21 and older does not
				  meet the clinical criteria in this subsection, prior authorization is required.
				  The agency reviews requests for prior authorization under WAC
				  182-501-0165.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › OXIMETERS › Section 182-552-0900 - Respiratory care - Covered - Oximeters

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency covers the purchase
				  of oximeters for clients eighteen years of age and older with prior
				  authorization as follows:
(a) One standard
				  oximeter, per client, every twenty-four months; or
(b) One enhanced oximeter, per client, every
				  thirty-six months.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › VENTILATORS › Section 182-552-1000 - Covered-Respiratory and ventilator equipment and supplies

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency covers the rental of
				  a ventilator, equipment, and disposable ventilator supplies when the client
				  requires periodic or continuous mechanical ventilation for the treatment of
				  chronic respiratory failure resulting from hypoxemia or hypercapnia.
(2) The agency's payment for the monthly
				  rental 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 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).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › SUCTION PUMPS › Section 182-552-1100 - Respiratory care - Covered - Suction pumps and supplies

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency covers suction pumps
				  and supplies when medically necessary for airway clearance or tracheostomy
				  suctioning.
(2) The medicaid agency
				  pays for a maximum of two suction devices per client in a five-year period as
				  follows:
(a) The medicaid agency rents one
				  primary suction device (stationary or portable) per client, for use in the home
				  and one secondary suction device, per client, for backup or
				  portability.
(b) The medicaid
				  agency considers the suction devices purchased after twelve months
				  rental.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › NONCOVERED SERVICES › Section 182-552-1200 - Respiratory care - Noncovered services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for respiratory
				  care only when listed as covered in this chapter. In addition to the noncovered
				  services found in WAC
				  182-501-0070, the medicaid agency
				  does not cover:
(a) Emergency or stand-by
				  oxygen systems;
(b) Portable
				  nebulizers;
(c) Kits and
				  concentrates for use in cleaning respiratory equipment;
(d) Intrapulmonary percussive ventilation
				  systems and related accessories;
(e) Batteries for a CPAP;
(f) Items or services which primarily serve
				  as a convenience for the client or caregiver;
(g) Oximetry checks;
(h) Loaner equipment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › AUTHORIZATION › Section 182-552-1300 - Respiratory care - Authorization

Current through Register Vol. 24-14, July 15, 2024
(1)
				  The medicaid agency requires providers to obtain authorization for covered
				  respiratory care as required in this chapter, chapters 182-501 and 182-502 WAC,
				  and in published agency medicaid provider guides and/or provider notices or
				  when the clinical criteria required in this chapter are not met.
(a) For prior authorization (PA), a provider
				  must submit a written request to the medicaid agency as specified in the
				  agency's published respiratory care medicaid provider guide.
(b) For expedited prior authorization (EPA),
				  a provider must document that the client has met the clinically appropriate EPA
				  criteria outlined in the medicaid provider guide. The appropriate EPA number
				  must be used when the provider bills the medicaid agency.
(c) Upon request, a provider must provide
				  documentation to the medicaid agency showing how the client's condition met the
				  criteria for PA or EPA.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › AUTHORIZATION › Section 182-552-1325 - Prior authorization

Current through Register Vol. 24-14, July 15, 2024
(1) The
				  medicaid agency requires providers to obtain prior authorization for certain
				  items and services before delivering that item or service to the client, except
				  when the items and services are covered by a third-party payer. The item or
				  service must also be delivered to the client before the provider bills the
				  medicaid agency.
(2) All prior
				  authorization requests must be accompanied by a completed General Information
				  for Authorization form (HCA 13-835), in addition to any program specific
				  medicaid agency forms as required within this chapter. Agency forms are
				  available on-line at
http://hrsa.dshs.wa.gov/mpforms.shtml
.
(3) When the medicaid agency receives the
				  initial request for prior authorization, the prescription(s) for those items or
				  services must not be older than three months from the date the agency receives
				  the request.
(4) The medicaid
				  agency requires certain information from providers in order to prior authorize
				  the purchase or rental of equipment. This information includes, but is not
				  limited to, the following:
(a) The
				  manufacturer's name;
(b) The
				  equipment model; and
(c) A detailed
				  description of the item.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › AUTHORIZATION › Section 182-552-1350 - Limitation extension (LE)

Current through Register Vol. 24-14, July 15, 2024
(1) The
				  medicaid agency limits the amount, frequency, or duration of certain covered
				  respiratory care, and reimburses up to the stated limit without requiring prior
				  authorization.
(2) Certain covered
				  items have limitations on quantity and frequency. These limits are designed to
				  avoid the need for prior authorization for items normally considered medically
				  necessary and for quantities sufficient for a thirty-day supply for one
				  client.
(3) The medicaid agency
				  requires a provider to request prior authorization for a limitation extension
				  (LE) in order to exceed the stated limits for respiratory care. All requests
				  for prior authorization must be accompanied by a completed General Information
				  for Authorization form (HCA 13-835) in addition to any program specific
				  medicaid agency forms as required within this chapter. Agency forms are
				  available on-line at
http://hrsa.dshs.wa.gov/mpforms.shtml
.
(4) The medicaid agency evaluates such
				  requests for LE under the provisions of WAC
				  182-501-0169.
Statutory Authority:
						RCW
						41.05.021. 12-14-022, §
												182-552-1350, filed 6/25/12,
						effective 8/1/12.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › AUTHORIZATION › Section 182-552-1375 - Expedited prior authorization (EPA)

Current through Register Vol. 24-14, July 15, 2024
(1) The expedited prior authorization (EPA)
				  process is designed to eliminate the need for written requests for prior
				  authorization for selected respiratory care procedure codes.
(2) The medicaid agency requires a provider
				  to create an authorization number for EPA for selected respiratory care
				  procedure codes. The process and criteria used to create the authorization
				  number is explained in the agency published respiratory care medicaid provider
				  guide. The authorization number must be used when the provider bills the
				  medicaid agency.
(3) Upon request,
				  a provider must provide documentation to the medicaid agency showing how the
				  client's condition met the criteria for EPA.
(4) A written request for prior authorization
				  is required when a situation does not meet the EPA criteria for selected
				  respiratory care procedure codes.
(5) The medicaid agency may recoup any
				  payment made to a provider under this section if the provider did not follow
				  the EPA process and criteria.
Statutory Authority:
						RCW
						41.05.021. 12-14-022, §
												182-552-1375, filed 6/25/12,
						effective 8/1/12.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › REIMBURSEMENT › Section 182-552-1400 - Respiratory care-Reimbursement-General

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays qualified
				  providers who meet all of the conditions in WAC
				  182-502-0100,
				  for covered respiratory care provided on a fee-for-service (FFS) basis as
				  follows:
(a) To medicaid agency-enrolled
				  medical equipment and supplies providers, pharmacies, and home health agencies
				  under their national provider identifier (NPI) numbers, subject to the
				  limitations of this chapter, and according to the procedures and codes in the
				  agency's current respiratory care medicaid billing guide; and
(b) In accordance with the health care common
				  procedure coding system (HCPCS) guidelines for product classification and code
				  assignment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › REIMBURSEMENT › Section 182-552-1500 - Respiratory care equipment and supplies - Reimbursement - Decision to rent or purchase

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency bases the decision to rent or purchase respiratory care equipment and
				  supplies for a client, or pay for repairs and associated labor for client-owned
				  equipment, on cost and on the length of time the client needs the
				  equipment.
(2) A provider must not
				  bill the medicaid agency for the rental or purchase of equipment supplied to
				  the provider at no cost by suppliers/manufacturers.
(3) The medicaid agency purchases new
				  equipment only.
(a) A new item that is placed
				  with a client initially as a rental item is considered a new item by the
				  medicaid agency at the time of purchase.
(b) A used item that is placed with a client
				  initially as a rental item must be replaced by the supplier with a new item
				  prior to purchase by the medicaid agency.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-552 - Respiratory care › REIMBURSEMENT › Section 182-552-1600 - Respiratory care equipment and supplies-Reimbursement-Methodology for purchase, rental, and repair

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency sets, evaluates, and updates the maximum allowable fees for respiratory
				  care equipment and supplies at least once yearly, unless otherwise directed by
				  the legislature or determined necessary by the agency.
(2) The agency sets the rates for medical
				  equipment codes subject to the federal financial participation (FFP) limitation
				  at the lesser of medicare's prevailing payment rates in the durable medical
				  equipment, prosthetics, or thotics, and supplies (DMEPOS) fee schedule or
				  competitive bid area (CBA) rate. For all other procedure codes, the agency sets
				  rates using one of the following:
(a)
				  Medicare fee schedules;
(b)
				  Legislative direction;
(c) Input
				  from stakeholders or relevant sources that the agency determines to be reliable
				  and appropriate;
(d) Pricing
				  clusters; or
(e) A by-report (BR)
				  basis.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-553 - Home infusion therapy/parenteral nutrition program › Section 182-553-100 - Home infusion therapy and parenteral nutrition program - General

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency's home infusion therapy and parenteral
				  nutrition program provides the supplies and equipment necessary for parenteral
				  infusion of therapeutic agents to Washington apple health clients. An eligible
				  client receives equipment, supplies, and parenteral administration of
				  therapeutic agents in a qualified setting to improve or sustain the client's
				  health.
11-14-075, recodified as §
											182-553-100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-19-057, § 388-553-100,
					 filed 9/14/10, effective 10/15/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.530. 04-11-007, §
					 388-553-100, filed 5/5/04, effective
					 6/5/04.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-553 - Home infusion therapy/parenteral nutrition program › Section 182-553-200 - Home infusion therapy/parenteral nutrition program - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following terms and definitions apply to the home
				  infusion therapy/parenteral nutrition program:
"Infusion therapy"
means the provision of
				  therapeutic agents or nutritional products to individuals by parenteral
				  infusion for the purpose of improving or sustaining a client's health.
"Intradialytic parenteral nutrition (IDPN)"
means intravenous nutrition administered during hemodialysis. IDPN is a form of
				  parenteral nutrition.
"Parenteral infusion"
means the introduction of
				  a substance by means other than the gastrointestinal tract, referring
				  particularly to the introduction of substances by intravenous, subcutaneous,
				  intramuscular or intramedullary means.
"Parenteral nutrition"
(also known as total
				  parenteral nutrition (TPN)) means the provision of nutritional requirements
				  intravenously.
11-14-075, recodified as §
											182-553-200, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.530. 04-11-007, §
					 388-553-200, filed 5/5/04, effective
					 6/5/04.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-553 - Home infusion therapy/parenteral nutrition program › Section 182-553-300 - Home infusion therapy/parenteral nutrition program - Client eligibility and assignment

Current through Register Vol. 24-14, July 15, 2024
(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:
(a) Have a written physician
				order 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) 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 care-giver may comply.
(e) 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) 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.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-553 - Home infusion therapy/parenteral nutrition program › Section 182-553-400 - Home infusion therapy and parenteral nutrition program - Provider requirements

Current through Register Vol. 24-14, July 15, 2024
(1)
				Eligible providers of home infusion supplies and equipment and parenteral
				nutrition solutions must:
(a)Have a signed
				core provider agreement with the medicaid agency; and
(b)Be one of the following provider types:
(i) Pharmacy provider;
(ii) Durable medical equipment (DME)
				provider; or
(iii) Infusion therapy
				provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-553 - Home infusion therapy/parenteral nutrition program › Section 182-553-500 - Home infusion therapy and parenteral nutrition program-Coverage, services, limitations, prior authorization, and reimbursement

Current through Register Vol. 24-14, July 15, 2024
(1) The home
				infusion therapy and parenteral nutrition program covers the following for
				eligible clients, subject to the limitations and restrictions listed:
(a) A one-month supply of home infusion , per
				client, per calendar month.
(b) A
				one-month supply of parenteral nutrition solu-tion, per client, per calendar
				month.
(c) One type of infusion
				pump, one type of parenteral pump, and one type of insulin pump per client, per
				calendar month and as follows:
(i) All
				rent-to-purchase infusion, parenteral, and 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.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-100 - Enteral nutrition - General

Current through Register Vol. 24-14, July 15, 2024
(1)
				The agency covers the enteral nutrition products, equipment, and related
				supplies listed in this chapter, according to medicaid agency rules and subject
				to the limitations and requirements in this chapter.
(2) The agency pays for covered enteral
				nutrition products, equipment and related supplies if they are:
(a)  Within the scope of the eligible
				client's medical care program;
(b)
				Medically necessary under WAC
				182-500-0070; and
(c) Authorized and billed, as required within
				this chapter, chapters 182-501 and 182-502 WAC, and the agency's published
				billing instructions.