The purpose of the children and youth with special health care needs (CYSHCN) program is to assure comprehensive, coordinated, integrated, family-centered, and culturally competent systems of care. The CYSHCN program focuses on developing, extending, and improving services and service systems for identifying, diagnosing, and treating infants, children, and youth up to eighteen years of age who have or are at risk of developing chronic physical, developmental, behavioral, or emotional conditions, or any combination thereof, and require health and related services of a type beyond what is required by children generally. The program works to ensure CYSHCN are able to achieve the healthiest lives possible and develop to their fullest potential by building the capacity of communities to support CYSHCN and their families while developing and enhancing the capacity of statewide systems of care that are comprehensive, coordinated, integrated, family-centered, community-based, and culturally appropriate with the purpose of supporting and promoting health equity.

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "Children and youth with special health care needs" or "CYSHCN" means children and youth up to eighteen years of age who have or are at increased risk of developing chronic physical, developmental, behavioral, or emotional conditions which require health and related services of a type or amount beyond that required by children generally.

(2) "Client" means a child or youth with special health care needs who is receiving services from a local CYSHCN agency.

(3) "CYSHCN program" means the program administered in the state of Washington by the department funded through the federal Title V Maternal Child Health block grant and other discretionary funding when available.

(4) "Department" means the Washington state department of health.

(5) "DX/TX funds" means diagnostic and treatment funds managed by the department that are used to pay for medically necessary services which are not covered by the HCA-medicaid program or other funding sources responsible and available for the care of a child or youth participating in the CYSHCN program.

(6) "Health care authority," "HCA," or "authority" means the state agency responsible for the administration of Washington state's medicaid program.

(7) "Local CYSHCN agency" means the local health jurisdiction or other local agency designated by the department to administer the CYSHCN program for the county where the client resides.

(8) "Nonphysician provider" means any medical, behavioral, developmental or social support worker or organization that has been determined by the department to provide services for CYSHCN, that does not hold an allopathic or osteopathic physician's license.

(9) "Services" means health-related interventions including, but not limited to:

(a) Early identification;

(b) Referrals for additional screening and diagnostic services;

(c) Care coordination;

(d) Case management;

(e) Family support;

(f) Health education and life skills;

(g) Medical, habilitative and rehabilitative services; and

(h) Equipment provided in the client's home or community setting by local CYSHCN agencies, physicians and nonphysician providers.

(1) A child, youth, or family with a current address in Washington state is eligible for services if the child or youth is younger than eighteen years of age, and has one or more of the following:

(a) A disability or disabling condition(s);

(b) Chronic illness or condition(s);

(c) Health-related educational or behavioral condition(s); or

(d) A risk of developing disabilities, chronic conditions, or health-related educational and behavioral conditions.

For the purposes of subsection (1) of this section, length of stay in the state is not considered in determining residency.

(2) Financial eligibility is not considered in determining client eligibility for the CYSHCN program except as outlined in subsection (3) of this section regarding DX/TX funds.

(3) Some services may be covered for established clients who are eighteen to twenty-one years of age, provided that the service or treatment:

(a) Was previously planned as a continued stage of treatment required to achieve health goals;

(b) Was initiated before the client turned eighteen;

(c) Has a definable treatment course with a clear end point; and

(d) Will not be authorized after a client's twenty-first birthday.

(4) A client may, at the discretion of the department, be eligible for DX/TX funds if they meet either of the following:

(a) Eligible for medicaid without monthly premiums; or

(b) Have current eligibility approved by the HCA-medicaid program, or the women, infants, and children program.

(5) A client shall request and the department shall determine DX/TX financial eligibility annually.

(6) DX/TX funds are not an entitlement. DX/TX funds are subject to medical necessity review by the local CYSHCN agency and availability of funding. The department may reduce the scope of CYSHCN services and impose or revise funding limitations on certain services when required for any reason including, but not limited to, budgetary reasons.

(7) For the purposes of this section, "medical necessity" means services which are reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent worsening of conditions that endanger life, cause suffering or pain, result in illness or infirmity, threaten to cause or aggravate a disability or health condition, for which there is no other equally effective, more conservative, or substantially less costly course of treatment available or suitable for the client. For the purposes of this definition, a course of treatment may include treatment, observation, or no treatment at all.

The department may authorize diagnostic and treatment services paid for with CYSHCN funds in accordance with the following:

(1) The department shall make decisions about using DX/TX funds on a case-by-case basis. DX/TX funds are not intended for those items that are part of usual daily living expenses that are the responsibility of parents/caregivers. DX/TX funds are not entitlement funds and the local CYSHCN agency or the department may choose not to use those funds.

(2) The department may only make a decision about whether to pay for services with DX/TX funds once all of the following have been completed:

(a) Determination of financial eligibility for a client;

(b) Department receipt, review, and approval of a HSA form submitted electronically to the department by the local CYSHCN agency;

(c) Services must be recognized as an acceptable form of treatment by a significant portion of the professional community; and

(d) Determination by the department that the services are medically necessary.

(3) The department will not authorize payment for services for out-of-state providers if an equivalent service is available within the state of Washington. If an equivalent service is not available in Washington state, services for out-of-state providers may be approved by the department on a case-by-case basis.

(4) For the purposes of this section, "Health Services Authorization form" or "HSA form" means an electronic form which must be completed by the local CYSHCN agency and submitted to the department for approval or denial in order to access DX/TX funds to pay for service, treatment, or equipment.

The department shall determine the eligibility of qualified medical and nonmedical providers to receive payment out of DX/TX funds. A service may not be authorized for out-of-state providers if an equivalent service is available within the state of Washington. The department may authorize the use of resources in bordering states when appropriate. Providers of services paid for with DX/TX funds shall meet the following minimum qualifications:

(1) Physicians, advanced registered nurse practitioners (ARNPs), and physician's assistants (PAs) must:

(a) Hold an active license in the jurisdiction where they practice;

(b) Be licensed, certified, or registered with the appropriate state authority and in good standing in the jurisdiction where they practice;

(c) Have no record of disciplinary action taken on his or her license in the previous five years; and

(d) Not be listed in the federal exclusions database.

(2) All other health providers not listed in subsection (1) of this section must:

(a) Where state or territorial licensing or certification exists for the person's profession, be:

(i) Licensed, certified, or registered with the appropriate state authority and in good standing in the jurisdiction where they practice; and

(ii) Have no record of disciplinary action taken on his or her license or certification in the previous five years; or

(b) Where state or territorial licensing or certification does not exist for the person's profession, be:

(i) Accredited by the appropriate national professional organization; and

(ii) Have no record of discipline or misconduct related to that accreditation within the previous five years.

(1) Payments to providers using DX/TX funds must be made using the current CYSHCN program standards and payment schedules, including the Washington state HCA-medicaid fee schedule and the CYSHCN program supplemental fee schedule.

(2) A provider shall consider payment to have been made in full for the services rendered when accepting the fees paid under this section.

(3) A provider may not bill or in any way seek billing or payment from a client for any remaining balances, unless the local CYSHCN agency has arranged for such billing before services were provided.

The department shall be the payor of last resort to all private and other publicly funded health programs. The department may pay for services with DX/TX funds only after payment by all entitlement programs and all other private and public funding resources have been exhausted, except where prohibited by federal law.

Repayment to the department from the provider, family or other source is required should insurance benefits, trusts, court-awarded damages or similar funds become available, and where payments have been made to the vendor or provider for services paid for by DX/TX funds. A provider shall provide repayment to the department for overpayment made for services paid out of DX/TX funds. In instances where repayment is required, the vendor or provider must refund the DX/TX payment to the local CYSHCN agency payable to the department which the local CYSHCN agency must transfer to the department.

(1) For the purposes of this section, "neurodevelopmental center (NDC) of excellence" means a department-designated nonprofit agency, hospital, or other organization located in Washington state that provides multidisciplinary pediatric assessment and treatment services including outreach, evaluation, diagnosis, treatment planning, and specialized therapies to CYSHCN up to twenty-one years of age.

(2) NDCs provide evaluation, diagnosis, and coordinated therapies and may also, at the discretion of a child's primary care provider, refer for additional medical specialty consultation.

(3) NDCs may be designated by the department as neurodevelopmental centers of excellence. In order to be considered for NDC designation by the department, a NDC shall:

(a) Be licensed or capable of becoming licensed to do business in the state of Washington;

(b) Maintain a formal relationship with a designated medical director with specialized pediatric training; and

(c) Employ occupational therapists licensed under chapter 18.59 RCW, physical therapists licensed under chapter 18.74 RCW, and speech language pathologists licensed under chapter 18.35 RCW with pediatric training on staff.

(1) The department's CYSHCN program has a federal mandate under Title V of the Social Security Act (42 U.S.C. 701 et seq.) to ensure that the HCA-medicaid program is made aware of medicaid-enrolled recipients of services through Title V. The purpose of this mandate is to ensure the medicaid agency is able to identify a child or youth who has special health care needs in order for the authority to offer care coordination and other services.

(2) The department shall take appropriate measures to safeguard any information gathered, and shall share information with only those agencies with a legitimate need to know or to comply with federal law. Consent to share client information with agencies outside of the local CYSHCN agency requires a separate release of information form signed by the parent or guardian.

(3) The department may create and release data files for public use, provided that these files do not contain any direct or indirect patient identifiers.

(4) The following definitions apply for the purpose of this section:

(a) "Direct identifier" means a single data element that identifies an individual person.

(b) "Indirect identifier" means a single data element that on its own might not identify an individual person, but when combined with other indirect identifiers is likely to identify an individual person.