PROPOSED RULES Filed 1/25/16, Effective 3/1/16) HEALTH CARE AUTHORITY [Filed February 7, 2019, 1:32 P.M.] WAC 182-545-400 Habilitative Services

Washington State Register, Issue 19-05 WSR 19-05-015 WSR 19-05-015 AMENDATORY SECTION (Amending WSR 16-04-026, PROPOSED RULES filed 1/25/16, effective 3/1/16) HEALTH CARE AUTHORITY [Filed February 7, 2019, 1:32 p.m.] WAC 182-545-400 Habilitative services. (1) Habilita- tive services assist the client in partially or fully attaining, Original Notice. learning, maintaining, or improving developmental-age Preproposal statement of inquiry was filed as WSR 18- appropriate skills that were not fully acquired as a result of a 21-010. congenital, genetic, or early acquired health condition. To the Title of Rule and Other Identifying Information: WAC extent practical, habilitative services maximize the client's 182-545-400 Habilitative services. ability to function in the client's environment. Hearing Location(s): On March 26, 2019, at 10:00 a.m., (2) Eligibility is limited to clients who are enrolled in the at the Health Care Authority (HCA), Cherry Street Plaza, Washington apple health alternative benefits plan defined in Pear Conference Room 107, 626 8th Avenue, Olympia, WA WAC 182-501-0060 ((and who have a diagnosis which is one 98504. Metered public parking is available street side around of the qualifying conditions listed in the agency's provider building. A map is available at https://www.hca.wa.gov/ guide for habilitative services)). Clients enrolled in an assets/program/Driving-parking-checkin-instructions.pdf or agency-contracted managed care organization (MCO) must directions can be obtained by calling 360-725-1000. arrange for habilitative services through their MCO. Date of Intended Adoption: Not sooner than March 27, (3) The following licensed health care professionals may 2019. enroll with the agency to provide habilitative services within Submit Written Comments to: HCA Rules Coordinator, their scope of practice to eligible clients: P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca. (a) Physiatrists; wa.gov, fax 360-586-9727, by March 26, 2019. (b) Occupational therapists; Assistance for Persons with Disabilities: Contact Amber (c) Occupational therapy assistants supervised by a Lougheed, phone 360-725-1349, fax 360-586-9727, telecom- licensed occupational therapist; munication relay services 711, email amber.lougheed@hca. (d) Physical therapists; wa.gov, by March 20, 2019. (e) Physical therapy assistants supervised by a licensed Purpose of the Proposal and Its Anticipated Effects, physical therapist; Including Any Changes in Existing Rules: The agency is (f) Speech-language pathologists who have been granted striking the outdated requirement in this section for a diagno- a certificate of clinical competence by the American Speech- sis of one of the qualifying conditions listed in the agency's Language-Hearing Association; and provider guide for habilitative services. The agency does not require the diagnosis of a specific condition for an eligible (g) Speech-language pathologists who have completed client to receive habilitative services and has removed the list the equivalent educational and work experience necessary for from the billing guide. such a certificate. Reasons Supporting Proposal: See purpose. (4) The agency pays for habilitative services that are: Statutory Authority for Adoption: RCW 41.05.021, (a) Covered within the scope of the client's alternative 41.05.160. benefits plan under WAC 182-501-0060; Statute Being Implemented: RCW 41.05.021, 41.05.160. (b) Medically necessary; Rule is not necessitated by federal law, federal or state (c) Within currently accepted standards of evidence- court decision. based medical practice; Name of Proponent: HCA, governmental. (d) Ordered by a physician, physician assistant, or an Name of Agency Personnel Responsible for Drafting: advanced registered nurse practitioner; Michael Williams, P.O. Box 42716, Olympia, WA 98504- (e) Begun within thirty calendar days of the date ordered; 2716, 360-725-1346; Implementation and Enforcement: (f) Provided by one of the health care professionals listed Tonja Nichols, P.O. Box 42716, Olympia, WA 98504-2716, in subsection (3) of this section; 360-725-1658. (g) Authorized under this chapter, chapters 182-501 and A school district fiscal impact statement is not required 182-502 WAC, and the agency's published provider guides; under RCW 28A.305.135. (h) Billed under this chapter, chapters 182-501 and 182- A cost-benefit analysis is not required under RCW 502 WAC, and the agency's published provider guides; and 34.05.328. RCW 34.05.328 does not apply to HCA rules (i) Provided as part of a habilitative treatment program: unless requested by the joint administrative rules review (i) In an office or outpatient hospital setting; committee or applied voluntarily. (ii) In the home, by a home health agency as described in The proposed rule does not impose more-than-minor chapter 182-551 WAC; or costs on businesses. Following is a summary of the agency's (iii) In a neurodevelopmental center, as described in analysis showing how costs were calculated. The revisions to WAC 182-545-900. this rule do not impose additional compliance costs or (5) For billing purposes under this section: requirements on providers. (a) Each fifteen minutes of timed procedure code equals February 7, 2019 one unit. Wendy Barcus (b) Each nontimed procedure code equals one unit, Rules Coordinator regardless of how long the procedure takes. [ 1 ] Proposed WSR 19-05-032 Washington State Register, Issue 19-05 (c) Duplicate services for habilitative services are not (f) Two program units for the provider to assess pros- allowed for the same client when both providers are perform- thetic or orthotic use, per client, per year. ing the same or similar procedure on the same day. (g) One muscle testing procedure, per client, per day. (d) The agency does not pay a health care professional (h) One wheelchair-needs assessment, per client, per for habilitative services performed in an outpatient hospital year. setting when the health care professional is not employed by (8) The agency evaluates requests for habilitative ser- the hospital. The hospital must bill the agency for the services that exceed the limitations in this section under WAC vices. 182-501-0169, for clients age twenty-one and older. For cli- (6) The limitations in subsection (7) of this section do ents age nineteen and twenty, the agency evaluates such not apply to eligible clients under age twenty-one. requests for medical necessity under chapter 182-534 WAC. (7) For eligible clients age twenty-one and older, the The agency requires prior authorization for additional units agency covers habilitative services that include an ongoing when: management plan for the client or the client's caregiver to (a) The criteria for EPA do not apply; support continued client progress. The agency limits habilita- (b) The number of available units under the EPA have tive services as follows: been used and services are requested beyond the limits; or (a) Occupational therapy, per client, per year: (c) The provider requests it as a medically necessary ser- (i) Without authorization: vice. (A) One occupational therapy evaluation; (9) The agency does not cover the following: (B) One occupational therapy reevaluation at time of dis- (a) Day habilitation services designed to provide train- charge; and ing, structured activities, and specialized services to adults; (C) Twenty-four units of occupational therapy (which (b) Services to assist basic needs; equals approximately six hours). (c) Vocational services; (ii) With expedited prior authorization (EPA), up to (d) Custodial services; twenty-four additional units of occupational therapy may be (e) Respite care; available when the therapy is required as part of an initial bot- (f) Recreational care; ulinum toxin injection protocol for spasticity or dystonia and (g) Residential treatment; botulinum toxin has been authorized by the agency. (h) Social services; and (b) Physical therapy, per client, per year: (i) Educational services of any kind. (i) Without authorization: (A) One physical therapy evaluation; (B) One physical therapy reevaluation at time of discharge; and WSR 19-05-032 (C) Twenty-four units of physical therapy (which equals PROPOSED RULES approximately six hours). HEALTH CARE AUTHORITY (ii) With EPA, up to twenty-four additional units of [Filed February 13, 2019, 9:17 a.m.] physical therapy may be available when the therapy is Original Notice. required as part of an initial botulinum toxin injection proto- Preproposal statement of inquiry was filed as WSR 18- col for spasticity or dystonia and botulinum toxin has been 09-111. authorized by the agency. Title of Rule and Other Identifying Information: WAC (c) Speech therapy, per client, per year: 182-538-040 Introduction, 182-538-050 Definitions, 182- (i) Without authorization: 538-060 Managed care choice and assignment, 182-538-067 (A) One speech language pathology evaluation; Qualifications to become a managed care organization (B) One speech language pathology reevaluation at the (MCO), 182-538-070 Payments to managed care organiza- time of discharge; and tions (MCOs), 182-538-095 Scope of care for managed care (C) Six units of speech therapy (which equals approxi- enrollees, 182-538-110 The grievance and appeal system and mately six hours). agency administrative hearing for managed care enrollees, (ii) With EPA, up to six additional units of speech ther- 182-538-120 Enrollee request for a second medical opinion, apy may be available when: 182-538-130 Exemptions and ending enrollment in managed (A) The therapy is required as part of an initial botuli- care, 182-538-140 Quality of care, and 182-538-150 Apple num toxin injection protocol for spasticity or dystonia and health foster care program. botulinum toxin has been authorized by the agency; or Hearing Location(s): On March 26, 2019, at 10:00 a.m., (B) The client has a speech deficit ((caused by the quali- at the Health Care Authority (HCA), Cherry Street Plaza, fying condition)) which requires a speech generating device.

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