PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: December 13, 2000.
Purpose: The department is establishing a new chapter for durable medical equipment, chapter 388-543 WAC, so that all the rules relating to this subject will be contained in one WAC chapter. The new chapter codifies current policy and payment methodology, in compliance with Failor's Pharmacy v. DSHS lawsuit. The proposed rules have been written to comply with the Governor's Executive Order 97-02.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.
Adopted under notice filed as WSR 00-13-008 on June 9, 2000.
Changes Other than Editing from Proposed to Adopted Version: WAC 388-543-1000:
"Expedited prior authorization" means the process for
obtaining authorization that must be used for selected durable
medical equipment....
"Limitation extension" means an authorization process to exceed coverage limitations (quantity, frequency, or duration) set in WAC, billing instructions, or numbered memoranda. Limitation extensions require prior authorization.
"Medical supplies" means supplies that are:
(1) Primarily and customarily used to service a medical purpose; and
(2) Generally not useful to a person in the absence of illness or injury.
"Personal or comfort item" means an item or service, which
primarily serves the comfort or convenience of the client. These
items or services do not contribute meaningfully to the treatment
of an illness or injury or the functioning of a malformed body
member.
"Prior authorization" means a process by which clients or
providers must request and receive MAA approval for certain
medical equipment and related supplies, prosthetics, orthotics,
medical supplies and related services, based on medical
necessity, before the services are provided to clients, as a
precondition for provider reimbursement. Expedited prior
authorization and limitation extension are forms types of prior
authorization.
"Three- or four-wheeled scooter" (5) Pneumatic rear tires.
Tires designed for indoor/outdoor use.
"Wheelchair - manual" means a federally-approved,
nonmotorized wheelchair that can be is capable of being
independently propelled by a client using his or her upper
extremities and fits one of the following categories:....
(1) MAA covers only those DME and related supplies,
prosthetics, orthotics, medical supplies and related services,
repairs and labor charges, listed in MAA's published issuances
(This proposed (1) renumbered as (6) as shown below.)
(2) (((2))) The Medical Assistance Administration (MAA)
covers DME and related supplies, prosthetics, orthotics, medical
supplies, related services, repairs and labor charges when all of
the following apply. They must be:
(f) Justified as Medically necessary as determined by MAA
defined in WAC 388-500-0005. The provider or client must submit
sufficient objective evidence to establish medical necessity.
Information used to establish medical necessity includes, but is
not limited to, the following:... (Proposed WAC 388-543-1100(2)
renumbered as (1).)
(2) MAA evaluates a request for any equipment or devices that are listed as noncovered in WAC 388-543-1300 under the provisions of WAC 388-501-0165.
(3) MAA evaluates a request for a service that is in a covered category but has been determined to be experimental or investigational under WAC 388-531-0050, under the provisions of WAC 388-501-0165 which relate to medical necessity.
(4) MAA evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions when medically necessary, under the standards for covered services in WAC 388-501-0165.
(5) (3) MAA does not reimburse for DME and related supplies,
prosthetics, orthotics, medical supplies, related services, and
related repairs and labor charges under fee-for-service (FFS)
when the client is any of the following:... (Proposed WAC 388-531-1100(3) renumbered as (5).)
(6) (1) MAA covers only those DME medical equipment and
related supplies, prosthetics, medical supplies and related
services, repairs and labor charges, listed in MAA's published
issuances, including Washington Administrative Code (WAC),
billing instructions, and numbered memoranda. (Proposed WAC 388-531-1100(1) renumbered as (6).)
(7) (4) MAA considers new technologies available through
manufacturers to be noncovered unless MAA establishes coverage by
assigning the technology a new procedure code an a reimbursement
rate, or by assigning an existing procedure code. A manufacturer
An interested party may request MAA to include new
equipment/supplies in the billing instructions by sending a
written request plass [plus] all of the following:
(d) Any additional information the manufacturer requestor
feels is important. (Proposed WAC 388-531-1100(4) renumbered as
(7).)
(8) (5) MAA bases the decision to purchase or rent DME for a
client, or to pay for repairs to client-owned equipment on the
least costly and/or equally effective alternative medical
necessity. (Proposed WAC 388-531-1100(5) renumbered as (8).)
(9) (6) MAA covers replacement batteries for purchased
medically necessary DME equipment covered within this chapter.
(Proposed WAC 388-531-1100(6) renumbered as (9).)
(10) (7) MAA covers the following categories of medical
equipment and supplies only when they are... (Proposed WAC 388-531-1100(7) renumbered as (10).)
(11) (8) MAA evaluates a BR item, procedure, or service for
its medical appropriateness and reimbursement value on a
case-by-case basis. (Proposed WAC 388-531-1100(8) renumbered as
(11).)
(12) (9) For a client in a nursing facility, MAA covers only
the following when medically necessary. All other DME and
supplies identified in MAA billing instructions are the
responsibility of the nursing facility, in accordance with
chapters 388-96 and 388-97 WAC. See also WAC 388-543-2900 (3)
and (4). MAA covers:
(a) The purchase and repair of an augmentative communication device (ACD), a wheelchair for the exclusive full-time use of a permanently disabled nursing facility resident when the wheelchair is not included in the nursing facility's per diem rate, or specialty bed; and
(b) The rental of a specialty bed. (Proposed WAC 388-531-1100(9) renumbered as (12).)
(13) Vendors must provide instructions for use of equipment; therefore instructional materials such as pamphlets and video tapes are not covered.
(14) Bilirubin lights are limited to rentals for at-home newborns with jaundice.
(1)(c) ...billed to the department. Out-of-state prosthetic and orthotics providers must meet their state regulatory requirements.
(2)(d) ...relative value scale (RBRVS); and
(e) Out-of-state orthotics and prosthetics providers who meet their state regulations.
WAC 388-543-1300 Noncovered Equipment, related supplies and
services or other nonmedical equipment supplies, and devices that
are not covered.
MAA pays only for medical equipment DME and related
supplies, and services that are medically necessary, listed as
covered, and meet MAA's the definition of DME and medical
supplies as defined in WAC 388-542-1000 and prescribed per WAC 388-543-1100 and 1200. MAA pays only for prosthetics and
orthotics that are listed as such by HCFA, meet the definitions
of prosthetic and orthotic as defined in WAC 388-542-1000, and
prescribed per WAC 388-542-1100 and 1200. . DME means equipment
that can withstand repeated use, is primarily and customarily
used to serve a medical purpose, generally is not useful to a
person in the absence of illness or injury, and is appropriate
for use in the client's place of residence. MAA considers all
requests for covered DME, related supplies and services, medical
supplies, prosthetics, orthotics, and related services, and
noncovered equipment and-related supplies, prosthetics,
orthotics, medical supplies and related services, will be
reviewed based on under the provisions of WAC 388-501-0165(8)
which relate to medical necessity. When MAA considers that a
request does not meet the requirements for medical necessity, the
definition(s) of covered item(s), or is not covered, the client
may appeal that decision under the provisions of WAC 388-501-0165. Case-by-case exceptions will only be considered
based on WAC 388-501-0160. MAA specifically excludes services
and equipment in this chapter from fee-for-service (FFS) scope of
coverage when the services and equipment do not meet the
definition for a covered item, or the services are not typically
medically necessary. This exclusion...
(3) More costly services or equipment when MAA determines
that less costly, equally effective services or equipment are
available;
(4) (3) A client's utility bills, even if operation or
maintenance of medical equipment purchased or rented by MAA for
the client contributes to an increased utility bill (refer to the
Aging and Adult Services Administration's (AASA) COPES program
for potential coverage);
(5) Bilirubin lights, except as rentals, for at-home
newborns with jaundice; (subsequent listing renumbered
appropriately).
(8) Procedures, prosthetics, or supplies related to gender
dysphoria surgery; (subsequent listing renumbered appropriately).
(10) (7) Outpatient office visit supplies and equipment used
during a physician office visit, such as tongue depressors and
surgical gloves;
(11) (8) Temporary prostheses or Prosthetic devices
dispensed solely for cosmetic reasons (refer to WAC 388-531-0150
(1)(d));
(12) (9) Home improvements and structural modifications,
including but not limited to the following:
(f) Structural modifications of any kind to a client's
house, including but not limited to, the following:
(i) (f) Electrical wiring...
(ii) (g) Elevator systems and elevators, ceiling lifts and
ceiling tracks, stair lifts.; and
(iii) (h) Wheelchair Lifts or ramps...
(iv) (i) Installation of...
(13) (10) Nonmedical equipment, supplies, and related
services, including but not limited to, the following:
(a) Backpacks, pouches, bags, baskets, or other carrying
containers for use with aids to mobility:
(b) Bed wetting (Enuresis) prevention training equipment; (c) (b) Beds other than hospital, Bedboards/conversion
kits...(subsequent listing renumbered appropriately).
(g) (f) Electronic communication equipment, installation
services, or service rates, including but not limited to, the
following:...
(ii) Interactive communications computer programs used between patients and healthcare providers (e.g., hospitals, physicians), for self care home monitoring, or emergency response systems and services (refer to AASA COPES or outpatient hospital programs for emergency response systems and services);
(m) (k) ...other than specified in WAC 388-543-23002200;
(l) Istructional materials, such as pamphlets and
videotapes; (subsequent listing renumbered appropriately).
(n) (l) Racing strollers/wheelchairs and purely recreational
equipment;
(p) (n) Sitz bath, Bidet or...
(q) (o) Timers or electronic devices to turn things on or
off; which are not an integral part of the equipment;
(14) (11) Personal and comfort items that do not meet the
DME definition, including but not limited to the following:...
(subsequent listing renumbered appropriately).
(a) Bathroom items, such as antiperspirant, astringent, bath
gel, conditioner, deodorant, moisturizer, mouthwash, powder,
sanitary napkins (e.g., Kotex), shampoo, shaving cream, shower
cap, shower curtains, soap (including antibacterial soap),
toothpaste, towels, and weight scales.
(e) Clothing protectors and other protective cloth furniture
coverings as protection against incontinence;
(f) Cosmetics, including corrective formulations, hair depilatories, and products for skin bleaching, commercial sun screens, and tanning;
(i) Emesis basins, enema bags, peri-wash, and diaper wipes;
(l) Hot water bottles and cold/hot packs or pads not otherwise covered by specialized therapy programs;
(15) (12)(g) Tie-down restraints, except where medically
necessary for client owned vehicles.
(2) MAA sets maximum allowable fees for DME medical
equipment...
(4) MAA updates the maximum allowable fees for DME medical
equipment...
(9) MAA does not cover medical equipment and/or services provided to a client who is enrolled in a MAA-contracted managed care plan, but did not use one of the plan's participating providers.
(1) MAA bases its determination about which DME and related supplies, prosthetics, orthotics, medical supplies and related services require prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria. (See WAC 388-543-1000 for PA and WAC 388-543-1800 for EPA). MAA considers all of the following when establishing utilization criteria:
(a) High cost;
(b) Potential for utilization abuse;
(c) Narrow therapeutic indication; and
(d) Safety.
(2) MAA requires providers to obtain prior authorization for certain items and services... (Items proposed as (1) through (16) renumbered as (2)(a) through (q).)
(p) ...procedure code; and
(q) Limitation extensions.
(6) If a client becomes ineligible before the end of the
month, MAA stops paying for any rented equipment effective the
date the client becomes ineligible. (subsequent listing
renumbered appropriately).
(8) MAA denies a request for an item when a less costly,
equally effective alternative is available that will meet the
client's medical needs. MAA informs the provider and/or the
client of a less costly alternative from MAA's manufacturer's
literature on file when an MAA denial of a request is based on a
less costly, equally effective alternative being available.
(1) MAA purchases a wheelchair for a client when MAA
determines that a wheelchair is medically necessary for more than
six months. MAA bases its decisions regarding requests for
wheelchairs on medical necessity and on a case-by-case basis.
(3) MAA considers rental or purchase of a manual wheelchair
if the for a home client who is nonambulatory or...
(b)(ii) Requires custom modifications that cannot be
provided on a standard weight wheelchair; and.
(4) MAA considers a power-drive wheelchair only if when the
client's medical needs cannot be met by a less costly means of
mobility.
(a) The client has severe abnormal upper extremity weakness
and the extent of the impairment is documented. (subsequent
listing renumbered appropriately).
(d) All other circumstances will be considered based on medical necessity and on a case-by-case basis.
(6) In order to consider purchasing a wheelchair, MAA requires the provider to submit the following information from the prescribing physician, physical therapist, or occupational therapist.
(10)(c)(iii) All other circumstances will be considered on a case-by-case basis, based on medical necessity.
(1) MAA considers all requests on a case-by-case basis for augmentative communication devices (ACDs) for the purpose of appropriately relaying medical information.
(2)(d) Documented trials of each ACD that the client has
tried. This includes less costly types/models, and the
effectiveness of each device in promoting the client's ability to
communicate with health care providers, and caregivers, and
others.
(3)(c)(ii) ...personal care needs; and
(iv) Improve excessive communication skills, vocabulary, and
understanding; and
(v) Attain specific speech therapy goals and objectives in the speech treatment or training plan.
(4) MAA covers ACDs only once every two years for a client
who meets the criteria in subsection (3) of this section. MAA
does not approve a new or updated component, modification, or
replacement model for a client whose ACD is less than two years
old. MAA may make exceptions to the criteria in this subsection
(3) of this section based strictly on a finding of unforeseeable
and significant changes to the client's medical condition.
(3) All other circumstances will be considered on a case-by-case basis, based on medical necessity.
(1) Beds covered by MAA are limited to hospital beds for rental or purchase. MAA bases the decision to rent or purchase a manual, semi-electric, or full electric hospital bed on the length of time the client needs the bed, as follows:...
(1)(a) MAA initially authorizes a maximum of two months rental for a short-term need. Upon request, MAA may allow limitation extensions as medically necessary.
(4) All other circumstances will be considered on a case-by-case basis, based on medical necessity.
(1) MAA reimburses for prosthetics and orthotics to licensed
prosthetic and orthotic providers only. This does not apply to:
selected prosthetics and orthotics that do not require special
skills to provide.
(a) Selected prosthetics and orthotics that do not require special skills to provide; and
(b) Out-of-state providers who meet the licensure requirements of that state.
WAC 388-543-2700 Prosthetics and orthotics reimbursement
methodology.
(4) MAA evaluates and updates the maximum allowable fees for prosthetics and orthotics at least once per year, independent of legislatively authorized vendor rate increases. Rates remain effective until the next rate change.
(5) MAA implements fee schedule changes for prosthetics and
orthotics July 1 of each year. Rates remain effective until the
next rate change. Reimbursement for prosthetics and orthotics is
limited to HCPC/National Codes with the same level of coverage as
Medicare.
(6) Reimbursement for gender dysphoria surgery includes payment for all related prosthetics and supplies.
(2) MAA bases its determination about which DME and related supplies, prosthetics, orthotics, medical supplies and related services require prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria (see WAC 388-543-1000 for PA and WAC 388-543-1800 for EPA). MAA considers all of the following when establishing utilization criteria:
(a) High cost;
(b) The potential for utilization abuse;
(c) A narrow therapeutic indication; and
(d) Safety.
(3) MAA requires a provider to obtain a limitation extension in order to exceed the stated limits for nondurable medical equipment and medical supplies. See WAC 388-501-0165.
(2) (4) MAA categorizes medical supplies and non-DME (MSE)
as follows (see MAA's billing instructions for specific
limitations):...
(k) Urological supplies (e.g., diapers, urinary retention catheters, pant liners and doublers); and
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 21, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 21, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 21, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.
December 13, 2000
Marie Myerchin-Redifer, Manager
Rules and policies Assistance Unit
Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 01-02 issue of the Register.