Section 182-553-500. Home infusion therapy and parenteral nutrition program—Coverage, services, limitations, prior authorization, and reimbursement.

(1) The home infusion therapy and parenteral nutrition program covers the following for eligible clients, subject to the limitations and restrictions listed:

(a) Home infusion supplies, limited to one month's supply per client, per calendar month.

(b) Parenteral nutrition solutions, limited to one month's supply per client, per calendar month.

(c) One type of infusion pump, one type of parenteral pump, and one type of insulin pump per client, per calendar month and as follows:

(i) All rent-to-purchase infusion, parenteral, and insulin pumps must be new equipment at the beginning of the rental period.

(ii) The agency covers the rental payment for each type of infusion, parenteral, or insulin pump for up to twelve months. The agency considers a pump purchased after twelve months of rental payments.

(iii) The agency covers only one purchased infusion pump or parenteral pump per client in a five-year period.

(iv) The agency covers only one purchased insulin pump per client in a four-year period.

(2) Covered supplies and equipment that are within the described limitations listed in subsection (1) of this section do not require prior authorization for reimbursement.

(3) The agency pays for FDA-approved continuous glucose monitoring systems and related monitoring equipment and supplies with prior authorization for a client who:

(a) Either has had one or more severe episodes of hypoglycemia or is enrolled in a trial approved by an institutional review board;

(b) Is age eighteen and younger;

(c) Has a diagnosis of insulin dependent diabetes mellitus; and

(d) Is followed by an endocrinologist.

(4) Requests for supplies or equipment that exceed the limitations or restrictions listed in this section require prior authorization and are evaluated on an individual basis according to the provisions of WAC 182-501-0165 and 182-501-0169.

(5) The agency may adopt policies, procedure codes, and rates inconsistent with those set by medicare.

(6) Agency reimbursement for equipment rentals and purchases includes the following:

(a) Instructions to a client, a caregiver, or both, on the safe and proper use of equipment provided;

(b) Full service warranty;

(c) Delivery and pickup; and

(d) Setup, fitting, and adjustments.

(7) The agency does not pay separately for home infusion supplies and equipment or parenteral nutrition solutions, except:

(a) When a client resides in a state-owned facility (e.g., state school, a developmental disabilities facility, a mental health facility, Western State Hospital, or Eastern State Hospital).

(b) When a client has elected and is eligible to receive the agency's hospice benefit, unless:

(i) The client has a preexisting diagnosis that requires parenteral support; and

(ii) The preexisting diagnosis is not related to the diagnosis that qualifies the client for hospice.

(8) The agency pays separately for a client's infusion pump, parenteral nutrition pump, insulin pump, solutions, and insulin infusion supplies when the client:

(a) Resides in a nursing facility; and

(b) Meets the criteria in WAC 182-553-300.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-063, § 182-553-500, filed 6/26/15, effective 7/27/15. Statutory Authority: RCW 41.05.021. WSR 12-16-059, § 182-553-500, filed 7/30/12, effective 8/30/12. WSR 11-14-075, recodified as § 182-553-500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-553-500, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-500, filed 5/5/04, effective 6/5/04.]

RCW 41.05.021 and 41.05.160. WSR 15-14-063, § 182-553-500, filed 6/26/15, effective 7/27/15. Statutory Authority: RCW 41.05.021. WSR 12-16-059, § 182-553-500, filed 7/30/12, effective 8/30/12. WSR 11-14-075, recodified as § 182-553-500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-553-500, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-500, filed 5/5/04, effective 6/5/04.

Rules

182-501-0165,182-501-0169,182-553-300,