Current through Register Vol. 24-18, September 15, 2024
(1) The following definitions and
abbreviations and those found in chapter 182-500 WAC apply to this chapter.
(a)
"Birthing center" means a
specialized facility licensed as a childbirth center by the department of
health (DOH) under chapter 246-349 WAC.
(b)
"Bundled services" means
services integral to the major procedure that are included in the fee for the
major procedure. Under this chapter, certain services which are customarily
bundled must be billed separately (unbundled) when the services are provided by
different providers.
(c)
"Facility fee" means the portion of the medicaid agency's payment
for the hospital or birthing center charges.
This does not include the agency's payment for the
professional fee.
(d)
"Global fee" means the fee the agency pays for total obstetrical
care. Total obstetrical care includes all bundled antepartum care, delivery
services and postpartum care.
(e)
"High-risk" pregnancy means any pregnancy that poses a significant
risk of a poor birth outcome.
(f)
"Professional fee" means the portion of the agency's payment for
services that rely on the provider's professional skill or training, or the
part of the reimbursement that recognizes the provider's cognitive skill. (See
WAC
182-531-1850
for reimbursement methodology.)
(2) The agency covers full scope medical
maternity care and newborn delivery services for fee-for-service and managed
care clients under WAC
182-501-0060.
(3) The agency does not provide
maternity care and delivery services to clients who are eligible for:
(a) Family planning only programs (a pregnant
client under these programs should be referred to the Washington
healthplanfinder via
www.wahealthplanfinder.org for
eligibility review); or
(b) Any
other program not listed in this section.
(4) The agency requires providers of
maternity care and newborn delivery services to meet all the following
requirements:
(a) Providers must be currently
licensed:
(i) By the state of Washington's
department of health (DOH), or department of licensing, or both; or
(ii) According to the laws and rules of any
other state, if exempt under federal law.
(b) Providers must have a signed core
provider agreement with the agency;
(c) Providers must be practicing within the
scope of their licensure; and
(d)
Providers must have valid certifications from the appropriate federal or state
agency, if such is required to provide these services (e.g., federally
qualified health centers (FQHCs), laboratories certified through the Clinical
Laboratory Improvement Amendment (CLIA)).
(5) The agency covers total obstetrical care
services (paid under a global fee). Total obstetrical care includes all the
following:
(a) Routine antepartum care that
begins in any trimester of a pregnancy;
(b) Delivery (intrapartum care and birth)
services; and
(c) Postpartum care.
This includes family planning counseling.
(6) When an eligible client receives all the
services listed in subsection (5) of this section from one provider, the agency
pays that provider a global obstetrical fee.
(7) When an eligible client receives services
from more than one provider, the agency pays each provider for the services
furnished. The separate services that the agency pays appear in subsection (5)
of this section.
(8) The agency
pays for antepartum care services in one of the following two ways:
(a) Under a global fee; or
(b) Under antepartum care fees.
(9) The agency's fees for
antepartum care include all the following:
(a) Completing an initial and any subsequent
patient history;
(b) Completing all
physical examinations;
(c)
Recording and tracking the client's weight and blood pressure;
(d) Recording fetal heart tones;
(e) Performing a routine chemical urinalysis
(including all urine dipstick tests); and
(f) Providing maternity counseling.
(10) The agency covers certain
antepartum services in addition to the bundled services listed in subsection
(9) of this section as follows:
(a) The
agency pays for either of the following, but not both:
(i) An enhanced prenatal management fee (a
fee for medically necessary increased prenatal monitoring). The agency provides
a list of diagnoses, or conditions, or both, that the agency identifies as
justification for more frequent monitoring visits; or
(ii) A prenatal management fee for
"high-risk" maternity clients. This fee is payable to either a physician or a
certified nurse midwife.
(b) The agency pays for both of the
following:
(i) Necessary prenatal laboratory
tests except routine chemical urinalysis, including all urine dipstick tests,
as described in subsection (9)(e) of this section; and
(ii) Treatment of medical problems that are
not related to the pregnancy. The agency pays these fees to physicians or
advanced registered nurse practitioners (ARNP).
(11) The agency covers high-risk pregnancies.
The agency considers a pregnant client to have a high-risk pregnancy when the
client:
(a) Has any high-risk medical
condition (whether or not it is related to the pregnancy); or
(b) Has a diagnosis of multiple
births.
(12) The agency
covers delivery services for clients with high-risk pregnancies, described in
subsection (11) of this section, when the delivery services are provided in a
hospital.
(13) The agency pays a
facility fee for delivery services in the following settings:
(a) Inpatient hospital; or
(b) Birthing centers.
(14) The agency pays a professional fee for
delivery services in the following settings:
(a) Hospitals, to a provider who meets the
criteria in subsection (4) of this section and who has privileges in the
hospital;
(b) Planned home births
and birthing centers.
(15) The agency covers hospital delivery
services for an eligible client as defined in subsection (2) of this section.
The agency's bundled payment for the professional fee for hospital delivery
services include:
(a) The admissions history
and physical examination; and
(b)
The management of uncomplicated labor (intrapar-tum care); and
(c) The vaginal delivery of the newborn (with
or without episiotomy or forceps); or
(d) Cesarean delivery of the
newborn.
(16) The agency
pays only a labor management fee to a provider who begins intrapartum care and
unanticipated medical complications prevent that provider from following
through with the birthing services.
(17) In addition to the agency's payment for
professional services in subsection (15) of this section, the agency may pay
separately for services provided by any of the following professional staff:
(a) A stand-by physician in cases of high
risk delivery, or newborn resuscitation, or both;
(b) A physician assistant or registered nurse
"first assist" when delivery is by cesarean section;
(c) A physician, ARNP, or licensed midwife
for newborn examination as the delivery setting allows; and
(d) An obstetrician, or gynecologist
specialist, or both, for external cephalic version and consultation.
(18) In addition to the
professional delivery services fee in subsection (15) or the global/total fees
(i.e., those that include the hospital delivery services) in subsections (5)
and (6) of this section, the agency allows additional fees for any of the
following:
(a) High-risk vaginal
delivery;
(b) Multiple vaginal
births. The agency's typical payment covers delivery of the first child. For
each subsequent child, the agency pays at fifty percent of the provider's usual
and customary charge, up to the agency's maximum allowable fee; or
(c) High-risk cesarean section
delivery.
(19) The
agency does not pay separately for any of the following:
(a) More than one child delivered by cesarean
section during a surgery. The agency's cesarean section surgery fee covers one
or multiple surgical births;
(b)
Postoperative care for cesarean section births. This is included in the
surgical fee. Postoperative care is not the same as, or part of, postpartum
care.
(20) The agency
pays for an early delivery, including induction or cesarean section, before
thirty-nine weeks of gestation only if medically necessary. The agency
considers an early delivery to be medically necessary:
(a) If the mother or fetus has a diagnosis
listed in the Joint Commission's current table of Conditions Possibly
Justifying Elective Delivery Prior to 39 Weeks Gestation; or
(b) If the provider documents a clinical
situation that supports medical necessity.
(21) The agency will only pay for antepartum
and post-partum professional services for an early elective delivery as defined
in WAC
182-500-0030.
(22) The hospital will receive no payment for
an early elective delivery as defined in WAC
182-500-0030.
(23) In addition to the services listed in
subsection (10) of this section, the agency covers counseling for tobacco
/nicotine cessation for eligible clients who are pregnant or in the postpartum
period as defined in
42
C.F.R. 435.170. See WAC
182-531-1720.
11-14-075, recodified as §182-533-0400, filed
6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090. 11-11-014, § 388-533-0400,
filed 5/9/11, effective 6/9/11. Statutory Authority:
RCW
74.08.090,
74.09.760, and
74.09.770. 05-01-065, §
388-533-0400, filed 12/8/04, effective 1/8/05; 02-07-043, § 388-533-0400,
filed 3/13/02, effective 4/13/02. Statutory Authority:
RCW
74.08.090,
74.09.760 through
74.09.800. 00-23-052, §
388-533-0400, filed 11/13/00, effective
12/14/00.
