Washington Administrative Code

(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 i…

(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).(2) Chemotherapy and …

(1) The medicaid agency calculates the enhanced ambulatory patient group (EAPG) payment as follows:EAPG payment =EAPG relative weight xHospital-specific conversion factor xDiscount factor (if applicable) xPolicy adjustor (if applicable)(2) The total OPPS claim payment is the sum …

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 iss…

(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 …

(1) The medicaid agency's hospice program is a 24 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 nonhospic…

The following definitions and abbreviations and those found in chapter 182-500 WAC, Medical definitions, apply to this subchapter."Authorized health care representative" - A person who has authority under RCW 7.70.065 to provide informed consent to terminate medical care or to el…

(1) Subject to the requirements and limitations in this chapter and other medicaid agency rules, a person who elects to receive hospice care must be eligible for:(a) One of the Washington apple health programs listed in the table in WAC 182-501-0060 with hospice as a covered bene…

(1) The medicaid agency reimburses a hospice agency for providing covered services through the medicaid agency's hospice daily rate.(2) Covered services include core services and supplies described in this section, subject to the requirements and limitations described in this sec…

(1) To become medicaid-approved, a hospice agency must be 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, subchapter I, Hospice services,…

(1) To become a medicaid-approved hospice care center, the hospice agency must be medicare-certified by the 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):(a) …

(1) Hospice coverage is available for two 90-day election periods followed by an unlimited number of 60-day election periods.(2) A client or a client's authorized health care representative must sign an election statement to initiate or reinitiate an election period for hospice c…

(1) The following describes the hospice certification process:(a) When a client or the client's authorized health care representative elects to receive hospice care, the medicaid agency requires a hospice agency to:(i) Obtain a signed written certification from a physician of the…

(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 246-335-640, and meet the requirements in this section.(2) …

(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 presc…

When a client chooses to leave hospice care or the client's authorized health care representative removes the client from hospice care and refuses hospice care without giving the hospice agency a revocation statement, as required by WAC 182-551-1360, the hospice agency must do al…

(1) A hospice agency may discharge a client from hospice care when the:(a) Client is no longer certified for hospice care;(b) Client is no longer appropriate for hospice care; or(c) Hospice agency's medical director determines the client is seeking treatment for the terminal illn…

(1) A client or a client's authorized health care representative may decide to stop hospice care at any time by signing a revocation statement.(2) The revocation statement documents the client's decision to stop medicaid hospice care. The revocation statement must include all of …

When a client dies, the hospice agency must:(1) Within five business days, notify the medicaid agency by completing the Medicaid Hospice Notification form (HCA 13-746) to the medicaid agency; and(2) Notify the appropriate department of social and health services (DSHS) home and c…

(1) To be reimbursed for providing hospice services, the hospice agency must:(a) Complete a Medicaid Hospice Notification form (HCA 13-746); and(b) Forward the form to the medicaid agency's hospice program within five business days from the date a Washington apple health client b…

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) R…

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 hos…

(1) The medicaid agency pays 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 physician…

(1) The medicaid agency does not pay the portion of hospice care for a client who 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 …

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 fo…

To receive pediatric palliative care (PPC) case management/coordination services, a person must:(1) Be 20 years of age or younger;(2) Be a current recipient of the:(a) Alternative benefit plan (ABP);(b) Categorically needy program (CNP);(c) Limited casualty program - Medically ne…

(1) The medicaid agency's pediatric palliative care (PPC) case management/coordination services allows, without prior authorization, up to six pediatric palliative care contacts per client, per calendar month, subject to the limitations in this section and other applicable WAC. S…

This section applies to medicaid-approved providers who currently do not provide pediatric palliative care (PPC) services to medicaid 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 18…

(1) An eligible provider of pediatric palliative care (PPC) case management/coordination services must:(a) Meet the requirements in WAC 182-551-1300;(b) Confirm that a client meets the eligibility criteria in WAC 182-551-1810 prior to providing the pediatric palliative care servi…

(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 t…

(1) In accordance with 42 U.S.C. 1396d (o)(1)(C), a client age 20 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 relate…

(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…

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to subchapter II:"Acute care" means care provided by a home health agency for clients who are not medically stable or have not attained a satisfactory level of rehabilitation. These clients r…

(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 thr…

(1) The medicaid 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…

(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)…

(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 se…

(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.(2) Outpatient rehabilitation and habilitative services are described in chapter 182-54…

(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 trea…

(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.[Statut…

The medicaid agency covers medical supplies, equipment, and appliances, as defined and described in chapter 182-543 WAC.[Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2122, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.0…

(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 medica…

(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 …

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)-certifie…

(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 …

(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 …

(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 canno…

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 pro…

(1) To be eligible for private duty nursing under the medically intensive children's program (MICP), clients must:(a) Be age 17 or younger;(b) Meet financial eligibility under subsection (2) of this section;(c) Meet medical eligibility under subsection (3) of this section;(d) Hav…

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 servic…