Wash. Admin. Code § 182-543-3000

Current through Register Vol. 24-23, December 1, 2024

Section 182-543-3000 - Covered - Hospital beds, mattresses, and related equipment

(1) Hospital beds.

(a) The medicaid agency covers, with prior authorization, one hospital bed in a ten-year period, per client, with the following limitations:

(i) A manual hospital bed as the primary option when the client has full-time caregivers; or

(ii) A semi-electric hospital bed only when:

(A) The client's medical need requires the client to be positioned in a way that is not possible in a regular bed and the position cannot be attained through less costly alternatives (e.g., the use of bedside rails, a trapeze, pillows, bolsters, rolled up towels or blankets);

(B) The client's medical condition requires immediate position changes;

(C) The client is able to operate the controls independently; and

(D) The client needs to be in the Trendelenburg position.

(b) The agency bases the decision to rent or purchase a manual or semi-electric hospital bed on the length of time the client needs the bed.

(c) Rental - The agency pays up to eleven months continuous rental of a hospital bed in a twelve-month period as follows:

(i) A manual hospital bed with mattress, with or without bed rails. The client must meet all of the following clinical criteria:

(A) Has a length of need/life expectancy that is twelve months or less;

(B) Has a medical condition that requires positioning of the body that cannot be accomplished in a standard bed (reason must be documented in the client's file);

(C) Has tried pillows, bolsters, and/or rolled up blankets/ towels in client's own bed, and these have been determined to not be effective in meeting the client's positioning needs (nature of ineffectiveness must be documented in the client's file);

(D) Has a medical condition that necessitates upper body positioning at no less than a thirty-degree angle the majority of time the client is in the bed;

(E) Does not have full-time caregivers; and

(F) Does not also have a rental wheelchair.

(ii) A semi-electric hospital bed with mattress, with or without bed rails. The client must meet all of the following clinical criteria:

(A) Has a length of need/life expectancy that is twelve months or less;

(B) Has tried pillows, bolsters, and/or rolled up blankets/ towels in own bed, and these have been determined to be ineffective in meeting positioning needs (nature of ineffectiveness must be documented in the client's file);

(C) Has a chronic or terminal condition such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), lung cancer or cancer that has metastasized to the lungs, or other pulmonary conditions that cause the need for immediate upper body elevation;

(D) Must be able to independently and safely operate the bed controls; and

(E) Does not have a rental wheelchair.

(d) Purchase - The agency pays, with prior authorization, for the initial purchase of a semi-electric hospital bed with mattress, with or without bed rails, when the following criteria are met:

(i) The client:

(A) Has a length of need/life expectancy that is twelve months or more;

(B) Has tried positioning devices such as pillows, bolsters, foam wedges, and/or rolled up blankets/towels in own bed, and these have been determined to be ineffective in meeting positioning needs (nature of ineffectiveness must be documented in the client's file);

(C) Must be able to independently and safely operate the bed controls; and

(D) Is diagnosed:

(I) With quadriplegia;

(II) With tetraplegia;

(III) With duchenne muscular dystrophy;

(IV) With amyotrophic lateral sclerosis (ALS), often referred to as "Lou Gehrig's Disease";

(V) As ventilator-dependent; or

(VI) With COPD or CHF with aspiration risk or shortness of breath that causes the need for an immediate change of upper body positioning of more than thirty degrees.

(ii) Requests for prior authorization must be submitted in writing to the agency and be accompanied by:

(A) A completed General Information for Authorization form HCA 13-835) and Hospital Bed Evaluation form HCA 13-747). The agency's electronic forms are available online (see WAC 182-543-7000, Authorization);

(B) Documentation of the client's life expectancy, in months and/or years, the client's diagnosis, the client's date of delivery and serial number of the hospital bed; and

(C) Be accompanied by written documentation, from the client or caregiver, indicating the client has not been previously provided a hospital bed, purchase or rental.

(2) Mattresses and related equipment - The agency pays, with prior authorization, for the following:

(a) Pressure pad, alternating with pump - One in a five-year period;

(b) Dry pressure mattress - One in a five-year period;

(c) Gel or gel-like pressure pad for mattress - One in a five-year period;

(d) Gel pressure mattress - One in a five-year period;

(e) Water pressure pad for mattress - One in a five-year period;

(f) Dry pressure pad for mattress - One in a five-year period;

(g) Mattress, inner spring - One in a five-year period; and

(h) Mattress, foam rubber - One in a five-year period.

Wash. Admin. Code § 182-543-3000

Amended by WSR 14-08-035, filed 3/25/14, effective 4/25/2014

11-14-075, recodified as §182-543-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. 11-14-052, § 388-543-3000, filed 6/29/11, effective 8/1/11. Statutory Authority: RCW 74.08.090, 74.09.530. 01-01-078, § 388-543-3000, filed 12/13/00, effective 1/13/01.