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PDFWAC 182-551-2130

Noncovered services.

(1) The medicaid agency does not cover the following home health services under the home health program, unless otherwise specified:
(a) Chronic long-term care skilled nursing visits or specialized therapy visits for a medically stable client when a long-term care skilled nursing plan or specialized therapy plan is in place through the department of social and health services' aging and long-term support administration (ALTSA).
(i) The medicaid agency considers requests for interim chronic long-term care skilled nursing services or specialized therapy services for a client while the client is waiting for ALTSA to implement a long-term care skilled nursing plan or specialized therapy plan; and
(ii) On a case-by-case basis, the medicaid agency may authorize long-term care skilled nursing visits or specialized therapy visits for a client for a limited time until a long-term care skilled nursing plan or specialized therapy plan is in place. Any services authorized are subject to the provisions in this section and other applicable published WAC.
(b) Social work services that are not "medical social services" as defined in WAC 182-551-2010.
(c) Psychiatric skilled nursing services.
(d) Pre- and postnatal skilled nursing services, except as listed under WAC 182-551-2100 (2)(e).
(e) Well-baby follow-up care.
(f) Services performed in hospitals, correctional facilities, skilled nursing facilities, or a residential facility with skilled nursing services available.
(g) Health care for a medically stable client (e.g., one who does not have an acute episode, a disease exacerbation, or treatment change).
(h) Home health specialized therapies and home health aide visits for clients that are covered under the AEM categorically needy and medically needy programs and are in the following programs:
(i) Categorically needy - Emergency medical only; and
(ii) Medically needy - Emergency medical only.
(i) Skilled nursing visits for a client when a home health agency cannot safely meet the medical needs of that client within home health services program limitations (e.g., for a client to receive infusion therapy services, the caregiver must be willing and capable of managing the client's care).
(j) More than one of the same type of specialized therapy and home health aide visit per day.
(k) The medicaid agency does not pay for duplicate services for any specialized therapy for the same client when both providers are performing the same or similar procedure or procedures.
(l) Home health visits made without a written physician's order, unless the verbal order is:
(i) Documented before the visit; and
(ii) The document is signed by the ordering physician within 45 days of the order being given.
(2) The medicaid agency does not cover additional administrative costs billed above the visit rate (these costs are included in the visit rate and will not be paid separately).
(3) The medicaid agency evaluates a request for any service that is listed as noncovered under WAC 182-501-0160.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-05-048, § 182-551-2130, filed 2/9/22, effective 3/12/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2130, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-03-035, § 182-551-2130, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2130, 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, § 388-551-2130, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-551-2130, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2130, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2130, filed 8/2/99, effective 9/2/99.]
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