HTML has links - PDF has Authentication

Chapter 182-553 WAC

Last Update: 12/10/18

HOME INFUSION THERAPY/PARENTERAL NUTRITION PROGRAM

WAC Sections

HTMLPDF182-553-100Home infusion therapy and parenteral nutrition program—General.
HTMLPDF182-553-200Home infusion therapy/parenteral nutrition program—Definitions.
HTMLPDF182-553-300Home infusion therapy/parenteral nutrition program—Client eligibility and assignment.
HTMLPDF182-553-400Home infusion therapy and parenteral nutrition program—Provider requirements.
HTMLPDF182-553-500Home infusion therapy and parenteral nutrition program—Coverage, services, limitations, prior authorization, and reimbursement.


PDF182-553-100

Home infusion therapy and parenteral nutrition programGeneral.

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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-152, § 182-553-100, filed 7/21/15, effective 8/21/15; WSR 15-08-103, § 182-553-100, filed 4/1/15, effective 5/2/15. WSR 11-14-075, recodified as § 182-553-100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-553-100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-100, filed 5/5/04, effective 6/5/04.]



PDF182-553-200

Home infusion therapy/parenteral nutrition program—Definitions.

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.
[WSR 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. WSR 04-11-007, § 388-553-200, filed 5/5/04, effective 6/5/04.]



PDF182-553-300

Home infusion therapy/parenteral nutrition program—Client eligibility and assignment.

(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 caregiver 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.
(5) To receive parenteral nutrition, a person must meet the conditions in subsection (4) of this section and:
(a) Have one of the following that prevents oral or enteral intake to meet the person's nutritional needs:
(i) Hyperemesis gravidarum; or
(ii) An impairment involving the gastrointestinal tract that lasts three months or longer.
(b) Be unresponsive to medical interventions other than parenteral nutrition; and
(c) Be unable to maintain weight or strength.
(6) A person who has a functioning gastrointestinal tract is not eligible for parenteral nutrition program services when the need for parenteral nutrition is only due to:
(a) A swallowing disorder;
(b) Gastrointestinal defect that is not permanent unless the person meets the criteria in subsection (7) of this section;
(c) A psychological disorder (such as depression) that impairs food intake;
(d) A cognitive disorder (such as dementia) that impairs food intake;
(e) A physical disorder (such as cardiac or respiratory disease) that impairs food intake;
(f) A side effect of medication; or
(g) Renal failure or dialysis, or both.
(7) A person with a gastrointestinal impairment that is expected to last less than three months is eligible for parenteral nutrition only if:
(a) The person's physician or appropriate medical provider has documented in the person's medical record the gastrointestinal impairment is expected to last less than three months;
(b) The person meets all the criteria in subsection (4) of this section;
(c) The person has a written physician order that documents the person is unable to receive oral or tube feedings; and
(d) It is medically necessary for the gastrointestinal tract to be totally nonfunctional for a period of time.
(8) A person is eligible to receive intradialytic parenteral nutrition (IDPN) solutions when:
(a) The parenteral nutrition is not solely supplemental to deficiencies caused by dialysis; and
(b) The person meets the criteria in subsection (4) and (5) of this section and other applicable WAC.
[Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-553-300, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-553-300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-553-300, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-300, filed 5/5/04, effective 6/5/04.]



PDF182-553-400

Home infusion therapy and parenteral nutrition programProvider requirements.

(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.
(2) The agency pays eligible providers for home infusion supplies and equipment and parenteral nutrition solutions only when the providers:
(a) Are able to provide home infusion therapy within their scope of practice;
(b) Have evaluated each client in collaboration with the client's physician, pharmacist, or nurse to determine whether home infusion therapy and parenteral nutrition is an appropriate course of action;
(c) Have determined that the therapies prescribed and the client's needs for care can be safely met;
(d) Have assessed the client and obtained a written physician order for all solutions and medications administered to the client in the client's residence or in a dialysis center through intravenous, epidural, subcutaneous, or intrathecal routes;
(e) Meet the requirements in WAC 182-502-0020, including keeping legible, accurate, and complete client charts, and providing the following documentation in the client's medical file:
(i) For a client receiving infusion therapy, the file must contain:
(A) A copy of the written prescription for the therapy;
(B) The client's age, height, and weight; and
(C) The medical necessity for the specific home infusion service.
(ii) For a client receiving parenteral nutrition, the file must contain:
(A) All the information listed in (e)(i) of this subsection;
(B) Oral or enteral feeding trials and outcomes, if applicable;
(C) Duration of gastrointestinal impairment; and
(D) The monitoring and reviewing of the client's lab values:
(I) At the initiation of therapy;
(II) At least once per month; and
(III) When the client, the client's lab results, or both, are unstable.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-152, § 182-553-400, filed 7/21/15, effective 8/21/15; WSR 15-08-103, § 182-553-400, filed 4/1/15, effective 5/2/15. WSR 11-14-075, recodified as § 182-553-400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-553-400, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-400, filed 5/5/04, effective 6/5/04.]



PDF182-553-500

Home infusion therapy and parenteral nutrition programCoverage, services, limitations, prior authorization, and reimbursement.

(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 solution, 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.
(2) Covered supplies and equipment that are within the described limitations listed in subsection (1) of this section do not require prior authorization for reimbursement.
(3) The agency pays for FDA-approved continuous glucose monitoring systems and related monitoring equipment and supplies using the expedited prior authorization process when the client meets the following criteria:
(a) Is age eighteen and younger;
(b) Is age nineteen and older with Type 1 diabetes;
(c) Is age nineteen and older with Type 2 diabetes who is:
(i) Unable to achieve target HbA1C despite adherence to an appropriate glycemic management plan after six months of intensive insulin therapy and testing blood glucose four or more times per day;
(ii) Suffering from one or more severe episodes of hypoglycemia despite adherence to an appropriate glycemic management plan; or
(iii) Unable to recognize, or communicate about, symptoms of hypoglycemia.
(d) Is pregnant with:
(i) Type 1 diabetes; or
(ii) Type 2 diabetes and on insulin prior to pregnancy;
(iii) Type 2 diabetes and whose blood glucose does not remain well controlled on diet or oral medication during pregnancy and requires insulin; or
(iv) Gestational diabetes with blood glucose that is not well controlled (HbA1C above target or experiencing episodes of hyperglycemia or hypoglycemia) and requires insulin.
(4) Requests for supplies or equipment that exceed the limitations or restrictions listed in this section require prior authorization and are evaluated on a case-by-case basis under WAC 182-501-0165 and 182-501-0169.
(5) The agency may adopt policies, procedure codes, and rates inconsistent with those set by medicare.
(6) Agency reimbursement for equipment rentals and purchases includes the following:
(a) Instructions to a client, a caregiver, or both, on the safe and proper use of equipment provided;
(b) Full service warranty;
(c) Delivery and pickup; and
(d) Setup, fitting, and adjustments.
(7) For clients residing in a state-owned facility (i.e., state school, developmental disabilities facility, mental health facility, Western State Hospital, and Eastern State Hospital) payment for home infusion supplies, equipment, and parenteral nutrition solutions are the responsibility of the state-owned facility to provide.
(8) For clients who are eligible for and have elected to receive the agency's hospice benefit, the agency pays for home infusion or parenteral nutrition supplies and equipment separately from the hospice per diem rate when:
(a) The client has a preexisting diagnosis that requires parenteral support; and
(b) The preexisting diagnosis is not related to the diagnosis that qualifies the client for hospice.
(9) For clients residing in a nursing facility, infusion pumps, parenteral nutrition pumps, insulin pumps, solutions, and insulin infusion supplies are not included in the nursing facility per diem rate. The agency pays for these items separately.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-01-024, § 182-553-500, filed 12/10/18, effective 2/1/19; WSR 15-14-063, § 182-553-500, filed 6/26/15, effective 7/27/15. Statutory Authority: RCW 41.05.021. WSR 12-16-059, § 182-553-500, filed 7/30/12, effective 8/30/12. WSR 11-14-075, recodified as § 182-553-500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-553-500, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-500, filed 5/5/04, effective 6/5/04.]