wa-law.org > bill > 2023-24 > SB 5103 > Second Substitute
"Medical assistance," notwithstanding any other provision of law, shall not include routine foot care, or dental services delivered by any health care provider, that are not mandated by Title XIX of the social security act unless there is a specific appropriation for these services.
The department shall adopt, amend, or rescind such administrative rules as are necessary to ensure that Title XIX personal care services are provided to eligible persons in conformance with federal regulations.
These administrative rules shall include financial eligibility indexed according to the requirements of the social security act providing for medicaid eligibility.
The rules shall require clients be assessed as having a medical condition requiring assistance with personal care tasks. Plans of care for clients requiring health-related consultation for assessment and service planning may be reviewed by a nurse.
The department shall determine by rule which clients have a health-related assessment or service planning need requiring registered nurse consultation or review. This definition may include clients that meet indicators or protocols for review, consultation, or visit.
The department shall design and implement a means to assess the level of functional disability of persons eligible for personal care services under this section. The personal care services benefit shall be provided to the extent funding is available according to the assessed level of functional disability. Any reductions in services made necessary for funding reasons should be accomplished in a manner that assures that priority for maintaining services is given to persons with the greatest need as determined by the assessment of functional disability.
Effective July 1, 1989, the authority shall offer hospice services in accordance with available funds.
For Title XIX personal care services administered by the department, the department shall contract with area agencies on aging or may contract with a federally recognized Indian tribe under RCW 74.39A.090(3):
To provide case management services to individuals receiving Title XIX personal care services in their own home; and
To reassess and reauthorize Title XIX personal care services or other home and community services as defined in RCW 74.39A.009 in home or in other settings for individuals consistent with the intent of this section:
Who have been initially authorized by the department to receive Title XIX personal care services or other home and community services as defined in RCW 74.39A.009; and
Who, at the time of reassessment and reauthorization, are receiving such services in their own home.
In the event that an area agency on aging or federally recognized Indian tribe is unwilling to enter into or satisfactorily fulfill a contract or an individual consumer's need for case management services will be met through an alternative delivery system, the department is authorized to:
Obtain the services through competitive bid; and
Provide the services directly until a qualified contractor can be found.
Subject to the availability of amounts appropriated for this specific purpose, the authority may offer medicare part D prescription drug copayment coverage to full benefit dual eligible beneficiaries.
Effective January 1, 2016, the authority shall require universal screening and provider payment for autism and developmental delays as recommended by the bright futures guidelines of the American academy of pediatrics, as they existed on August 27, 2015. This requirement is subject to the availability of funds.
Subject to the availability of amounts appropriated for this specific purpose, effective January 1, 2018, the authority shall require provider payment for annual depression screening for youth ages twelve through eighteen as recommended by the bright futures guidelines of the American academy of pediatrics, as they existed on January 1, 2017. Providers may include, but are not limited to, primary care providers, public health nurses, and other providers in a clinical setting. This requirement is subject to the availability of funds appropriated for this specific purpose.
Subject to the availability of amounts appropriated for this specific purpose, effective January 1, 2018, the authority shall require provider payment for maternal depression screening for mothers of children ages birth to six months. This requirement is subject to the availability of funds appropriated for this specific purpose.
Subject to the availability of amounts appropriated for this specific purpose, the authority shall:
Allow otherwise eligible reimbursement for the following related to mental health assessment and diagnosis of children from birth through five years of age:
Up to five sessions for purposes of intake and assessment, if necessary;
Assessments in home or community settings, including reimbursement for provider travel; and
Require providers to use the current version of the DC:0-5 diagnostic classification system for mental health assessment and diagnosis of children from birth through five years of age.
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Subject to the availability of amounts appropriated for this specific purpose, the authority shallrequire or provide payment to the hospital for any day of a hospital stay in which an adult or child patient enrolled in medical assistance, including home and community services or with a medicaid managed care organization, under this chapter:
Does not meet the criteria for acute inpatient level of care as defined by the authority;
Meets the criteria for discharge, as defined by the authority or department, to any appropriate placement including, but not limited to:
(A) A nursing home licensed under chapter 18.51 RCW;
(B) An assisted living facility licensed under chapter 18.20 RCW;
(C) An adult family home licensed under chapter 70.128 RCW; or
(D) A setting in which residential services are provided or funded by the developmental disabilities administration of the department, including supported living as defined in RCW 71A.10.020; and
iii. Is not discharged from the hospital because placement in the appropriate location described in (a)(ii) of this subsection is not available.
The authority shall adopt rules identifying which services are included in this rate and which services may be billed separately, including specific revenue codes or services required on the inpatient claim.
b. Allowable medically necessary services performed during a stay described in (a) of this subsection shall be billed by and paid to the hospital separately. Such services may include but are not limited to hemodialysis, laboratory charges, and x-rays.
c. Pharmacy services and pharmaceuticals shall be billed and paid separately.
d. The requirements of this subsection do not alter requirements for billing or payment for inpatient care.
e. The authority shall adopt, amend, or rescind such administrative rules as necessary to facilitate calculation and payment of the amounts described in this subsection, including for clients of medicaid managed care organizations.
f. The authority shall adopt rules requiring medicaid managed care organizations to establish specific and uniform administrative and review processes for payment under this subsection.
g. For patients meeting the criteria in (a)(ii)(A) of this subsection, hospitals must utilize swing beds or skilled nursing beds within their facility and the associated reimbursement methodology prior to the billing under the methodology in (b) of this subsection, if the hospital determines that such swing bed or skilled nursing bed placement is appropriate for the patient's care needs, the patient is appropriate for the existing patient mix, and appropriate staffing is available.