Current through Register Vol. 24-18, September 15, 2024
(1)
Habilita-tive services assist the client in partially or fully attaining,
learning, maintaining, or improving developmental-age appropriate skills that
were not fully acquired as a result of a congenital, genetic, or early acquired
health condition. To the extent practical, habilitative services maximize the
client's ability to function in the client's environment.
(2) Eligibility is limited to clients who are
enrolled in the Washington apple health alternative benefits plan defined in
WAC
182-501-0060.
Clients enrolled in an agency-contracted managed care organization (MCO) must
arrange for habilitative services through their MCO.
(3) The following licensed health care
professionals may enroll with the agency to provide habilitative services
within their scope of practice to eligible clients:
(a) Physiatrists;
(b) Occupational therapists;
(c) Occupational therapy assistants
supervised by a licensed occupational therapist;
(d) Physical therapists;
(e) Physical therapy assistants supervised by
a licensed physical therapist;
(f)
Speech-language pathologists who have been granted a certificate of clinical
competence by the American Speech-Language-Hearing Association; and
(g) Speech-language pathologists who have
completed the equivalent educational and work experience necessary for such a
certificate.
(4) The
agency pays for habilitative services that are:
(a) Covered within the scope of the client's
alternative benefits plan under WAC
182-501-0060;
(b) Medically necessary;
(c) Within currently accepted standards of
evidence-based medical practice;
(d) Ordered by a physician, physician
assistant, or an advanced registered nurse practitioner;
(e) Begun within thirty calendar days of the
date ordered;
(f) Provided by one
of the health care professionals listed in subsection (3) of this
section;
(g) Authorized under this
chapter, chapters 182-501 and 182-502 WAC, and the agency's published provider
guides;
(h) Billed under this
chapter, chapters 182-501 and 182-502 WAC, and the agency's published provider
guides; and
(i) Provided as part of
a habilitative treatment program:
(i) In an
office or outpatient hospital setting;
(ii) In the home, by a home health agency as
described in chapter 182-551 WAC; or
(iii) In a neurodevelopmental center, as
described in WAC
182-545-900.
(5) For billing
purposes under this section:
(a) Each fifteen
minutes of timed procedure code equals one unit.
(b) Each nontimed procedure code equals one
unit, regardless of how long the procedure takes.
(c) Duplicate services for habilitative
services are not allowed for the same client when both providers are performing
the same or similar procedure on the same day.
(d) The agency does not pay a health care
professional for habilitative services performed in an outpatient hospital
setting when the health care professional is not employed by the hospital. The
hospital must bill the agency for the services.
(6) The limitations in subsection (7) of this
section do not apply to eligible clients under age twenty-one.
(7) For eligible clients age twenty-one and
older, the agency covers habilitative services that include an ongoing
management plan for the client or the client's caregiver to support continued
client progress. The agency limits habilita-tive services as follows:
(a) Occupational therapy, per client, per
year:
(i) Without authorization:
(A) One occupational therapy
evaluation;
(B) One occupational
therapy reevaluation at time of discharge; and
(C) Twenty-four units of occupational therapy
(which equals approximately six hours).
(ii) With expedited prior authorization
(EPA), up to twenty-four additional units of occupational therapy may be
available when the therapy is required as part of an initial bot-ulinum toxin
injection protocol for spasticity or dystonia and botulinum toxin has been
authorized by the agency.
(b) Physical therapy, per client, per year:
(i) Without authorization:
(A) One physical therapy
evaluation;
(B) One physical
therapy reevaluation at time of discharge; and
(C) Twenty-four units of physical therapy
(which equals approximately six hours).
(ii) With EPA, up to twenty-four additional
units of physical therapy may be available when the therapy is required as part
of an initial botulinum toxin injection protocol for spasticity or dystonia and
botulinum toxin has been authorized by the agency.
(c) Speech therapy, per client, per year:
(i) Without authorization:
(A) One speech language pathology
evaluation;
(B) One speech language
pathology reevaluation at the time of discharge; and
(C) Six units of speech therapy (which equals
approximately six hours).
(ii) With EPA, up to six additional units of
speech therapy may be available when:
(A) The
therapy is required as part of an initial botuli-num toxin injection protocol
for spasticity or dystonia and botulinum toxin has been authorized by the
agency; or
(B) The client has a
speech deficit which requires a speech generating device.
(d) Two durable medical equipment
needs assessments, per client, per year. The agency covers devices and other
durable medical equipment for habilitative purposes under chapter 182-543
WAC.
(e) Two program units of
orthotics management and training of upper and lower extremities, per client,
per day.
(f) Two program units for
the provider to assess prosthetic or orthotic use, per client, per
year.
(g) One muscle testing
procedure, per client, per day.
(h)
One wheelchair-needs assessment, per client, per year.
(8) The agency evaluates requests for
habilitative services that exceed the limitations in this section under WAC
182-501-0169,
for clients age twenty-one and older. For clients age nineteen and twenty, the
agency evaluates such requests for medical necessity under chapter 182-534 WAC.
The agency requires prior authorization for additional units when:
(a) The criteria for EPA do not
apply;
(b) The number of available
units under the EPA have been used and services are requested beyond the
limits; or
(c) The provider
requests it as a medically necessary service.
(9) The agency does not cover the following:
(a) Day habilitation services designed to
provide training, structured activities, and specialized services to
adults;
(b) Services to assist
basic needs;
(c) Vocational
services;
(d) Custodial
services;
(e) Respite
care;
(f) Recreational
care;
(g) Residential
treatment;
(h) Social services;
and
(i) Educational services of any
kind.
