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PDFWAC 182-551-2100

Covered skilled nursing services.

(1) The medicaid agency covers the home health acute care skilled nursing services without prior authorization subject to the provisions in this section. Additional services require prior authorization and are granted if medically necessary, as defined in WAC 182-500-0070. The agency evaluates a request for home health acute care skilled nursing services that are listed as noncovered:
(a) For a person age 21 and older, according to WAC 182-501-0160;
(b) For a person age 20 and younger, under the early and periodic screening diagnosis and treatment (EPSDT) provisions in chapter 182-543 WAC; and
(c) For a person age 19 or older that is under emergency related services only, according to WAC 182-507-0120.
(2) The home health acute care skilled nursing services must be furnished by a qualified provider in any setting where normal life activities take place.
(3) The medicaid agency covers the following home health acute care skilled nursing services, subject to the provisions in this section:
(a) Full skilled nursing services that require the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse, if the services involve one or more of the following:
(i) Observation;
(ii) Assessment;
(iii) Treatment;
(iv) Teaching;
(v) Training;
(vi) Management; and
(vii) Evaluation.
(b) A brief skilled nursing visit if only one of the following activities is performed during the visit:
(i) An injection;
(ii) Blood draw; or
(iii) Placement of medications in containers (e.g., envelopes, cups, medisets).
(c) Home infusion therapy only if the client:
(i) Is willing and capable of learning and managing the client's infusion care; or
(ii) Has a volunteer caregiver willing and capable of learning and managing the client's infusion care.
(d) Infant phototherapy for an infant diagnosed with hyperbilirubinemia:
(i) When provided by a medicaid agency-approved infant phototherapy agency; and
(ii) For up to five skilled nursing visits per infant.
(e) Limited high-risk obstetrical services:
(i) For a medical diagnosis that complicates pregnancy and may result in a poor outcome for the mother, unborn, or newborn;
(ii) For up to three home health visits per pregnancy if enrolled in or referred to a first steps maternity support services (MSS) provider. The visits are provided by a registered nurse who has either:
(A) National perinatal certification; or
(B) A minimum of one year of labor, delivery, and postpartum experience at a hospital within the last five years.
(4) The medicaid agency limits skilled nursing visits provided to eligible clients to two per day.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2100, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2100, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2100, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2100, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2100, filed 8/2/99, effective 9/2/99.]
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