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Molina Healthcare of Washington, Inc.

Provider Orientation Materials -

FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) RURAL HEALTH CLINICS (RHC)

HRSA pays a monthly amount, known as an enhancement rate, to clinics designated and approved as FQHCs and RHCs. There are three types of enhancement rates:

• Per Member Per Month (PMPM) premium enhancement • Delivery Case Rate (DCR) enhancement • BH Maternity S supplemental DCR

These enhancement rates are paid by HRSA directly to the clinics. Each FQHC and RHC is responsible to notify Molina Healthcare of any changes (additions and terminations) in Providers at the clinic. Members are assigned to individual Providers and monthly reporting is based on Provider information received from clinics. PMPM Premium Enhancement: All FQHC and RHC clinics receive this premium enhancement rate established annually by HRSA. Molina Healthcare submits monthly eligibility rosters to HRSA, listing all Members assigned to PCPs for each of its contracted FQHC’s and RHC’s. HRSA determines its PMPM payment based on that roster. Any payment discrepancies identified by Providers must be addressed to HRSA. DCR and BH S Rate Enhancements: Some FQHC and RHC clinics also receive a DCR or BH S rate enhancement from HRSA. HRSA requires the FQHC’s and RHC’s to bill HRSA directly for the DCR and BH S enhancements. Please note the DCR enhancement differs from the straight DCR payment.



Quick Reference Guide ADDRESSES

CLAIMS

EDI Payer ID Number = 38336

Molina Healthcare of Washington Claims PO Box 22612 Long Beach, CA 90801

Local – Bothell Office

PO Box 4004

Bothell WA 98041-4004

Local – Spokane Office PO Box 2470

Spokane WA 99210-2470

TELEPHONE NUMBERS

Main Office – Bothell, WA & Spokane, WA

Phone: (800) 869-7175 or (425) 424-1100

Nurse Advise Line (24-Hours)

Phone: (888) 275-8750

Member Services

Interactive Voice Response System for current Member eligibility

Phone: (800) 869-7165 or (425) 424-1103 Fax: (800) 816-3778 or (425) 424-1163

Phone: (800) 869-7165 Option 1

Authorizations & Hospital Admissions Phone: (800) 869-7185 or (425) 424-1109

Fax: (800) 767-7188 or (425) 424-1161

Pharmacy Authorizations: The Molina Healthcare formulary is available at www.ePocrates.com or www.molinahealthcare.com

Phone: (800) 213-5525

Fax: (800) 869-7791

Behavioral/Mental Health Authorizations Phone: (800) 695-2115 Fax: (800) 334-8979

Provider Claims Inquiry Phone: (800) 745-4044 or (425) 424-1108

Credentialing Department Phone: (800) 423-9899 or (509) 321-1300

Fax: (800) 882-8053 or (509) 321-1381

Health Education Department Phone: (800) 423-9899 or (509) 321-1382 Fax: (800) 461-3234



CLAIMS – Quick Reference ADDRESS: Molina Healthcare of Washington, Inc. PO Box 22612

Long Beach CA 90801 EDI CLAIMS: Molina Healthcare Payer ID # is 38336

INQUIRIES: Provider Claim Inquiries (800) 745-4044 Website: www.molinahealthcare.com / Provider Self Services

PROVIDER APPEALS: Request for a Denied Claims Review should be sent to:

Molina Healthcare Molina Healthcare Provider Services OR Provider Services

PO Box 4004 PO Box 2470 Bothell, WA 98041-4004 Spokane, WA 99210-2470

TIMELY FILING: Claims must be received by Molina Healthcare within 180 days from

date of service. ADDITIONAL Additional information to process a claim, when requested by INFORMATION: Molina Healthcare, must be received within 60 days from the date of

request. PAYMENT: Checks are mailed weekly to Providers. REFUNDS: Provider finds overpayment – Send refund with copy of the

Remittance Advice (RA) and claim information to: Molina Healthcare PO Box 4004 Bothell, WA 98041-4004

If a Provider receives a check that is not theirs, please return it to the above address. Molina Healthcare finds an overpayment – In the event Molina Healthcare finds an overpayment or incorrect payment for services provided to Molina Healthcare Members, a letter requesting the refund will be mailed to the Provider. If Molina Healthcare does not receive a refund or written notice to contest a refund request within 45 days, we will automatically retract monies overpaid from future payments.

BILLING: As a general rule, Molina Healthcare primarily follows the DSHS billing guidelines. This does not apply to all DSHS billing guidelines for claims processing or timely filing. Please refer to the Claims and Encounter Data section of Molina Healthcare's Provider Manual.



MOLINA HEALTHCARE’S WEB BASED PROVIDER SELF SERVICES

This section will introduce Molina Healthcare’s Provider Self Services website. This site will allow you to access information from any computer at any time.

Features

• New User Registration-Provider will be able to enter the required information and get access immediately

• Secure Log In-Provider will enter their User ID and Password and will be able to access the system. A 128 bit secured logon has been implemented.

• Change Password-Provider will be able to change the password whenever he\she wants • Forgot Password-Provider will be able to request their password if he forgets the

password • Member Eligibility Inquiry-Provider will be able to view member’s eligibility and current

PCP • Provider Search-Provider will be able to search for other Molina Healthcare Providers • Authorization status inquiry-Provider will be able to view the status of an Authorization

that has been submitted • Authorization submission-Provider can submit Authorization requests to Molina

Healthcare on-line • Claim status inquiry-Provider can view the status of their Claims • Contact Us-Enables providers to contact Molina Healthcare. The Provider can also send

an e-mail message through this link to respective group mail ID. • Patient Listing-Enables Primary Care Providers to get the list of Members who are

eligible on a particular date • Frequently Asked Questions-Lists the frequently asked questions for using the site • View/Update Profile-Provider can view his/her profile and can also request a change of

profile through the website. The change request will be sent to the respective group mail ID.

• Download Forms-Provider will be able to download frequently used forms



• Go to the Molina Healthcare website: www.molinahealthcare.com

• Click on Provider Self Services

• If you have not registered, click on ‘New Provider Registration’ and follow the

prompts to register • If you previously registered and have forgotten your password, click the ‘Forgot

Password?’ link and follow the prompts • If you previously registered and have forgotten your user name, please call (866) 449-

6848 for assistance



Provider Self Services Home Page View

From the Home Page, you will be able to:

• View Member Eligibility • View Claims Status • View Authorization Status • Download Remittance Advices • Create Patient Eligibility Lists • Submit an Authorization Request

Please contact your Provider Services Representative if you have questions regarding any of the features of the Provider Self Services system or if you would like to schedule additional training for your staff. FREQUENTLY ASKED QUESTIONS:

How do I register myself on the Provider Self Services portal? • Click on ‘New Provider Registration’ • Read the ‘Online User Agreement: E-Access’ carefully and accept only if you agree

with all the clauses of the agreement • Fill in the Provider details. The fields with * are mandatory fields. Fill in the User ID

and password you want to log into the Provider Self Services portal. Once your details are found to be correct, your User ID and password are sent to your e-mail ID.

After this, the registration process is complete and you can now use the functionalities of the Provider Self Services portal. Keep your User ID and password confidential.



How do I Log In? Input your User ID and password to log in. You can log in only after you have initially registered. How do I change my password? Click on ‘Change Password,’ which is available on the right hand side menu. Enter your old password then enter the new password. Confirm the new password. I have forgotten my password. What do I do? Click on ‘Forgot Password’ on the log-in page. Enter your User ID, followed by your Tax ID. Your password will be emailed to you. How do I inquire for the Member Eligibility online? Log-in to the portal with your User ID and password. Click on ‘Member Eligibility.’ Search by one or more criteria as the interface shows. Click on ‘Search.’ You can now view the summary of the Member eligibility. How do I inquire for the authorization status of my patients online? Log-in to the portal using your User ID and password. Click on ‘Authorization.’ Search by one or more criteria as the interface shows. Click on ‘Search.’ You can now view the summary of the Authorizations. Click on ‘View Details’ to view the Authorization details. How do I view the details of my claims online? Log-in to the portal using your User ID and password. Click on ‘Claims.’ Search by one or more criteria as the interface shows. Click on ‘Search.’ You can now view the summary of the claims according to your search criteria. Click on ‘View Details’ to view the details of the claims. How do I change my profile online? Log-in to the portal using your User ID and password. Click on ‘View / Update Profile’ to view your profile. Click on ‘Edit’ to change the fields which are shown. Once you confirm your changes, the request is sent to Provider Services to make the appropriate updates. You will also be able to add your NPI numbers. Can I view a list of my own patients online? Log-in to the portal using your User ID and password. Click on ‘View Patients List’. You may now view and download your list of Molina Healthcare members. How do I contact Molina Healthcare? Log-in to the portal using your User ID and password. Click on ‘Contact Us’. Fill in the text, click ‘Submit’ and Molina Healthcare Pro



WASHINGTON MEDICAID INTEGRATION PARTNERSHIP This section is intended to provide you with information regarding the Washington Medicaid Integration Partnership (WMIP) project. The Department of Social and Health Services (DSHS) has established a pilot program in Snohomish County wherein Medicaid clients who receive benefits under the Aged, Blind and Disabled Program Supplemental Security Income (SSI) may elect to enroll with Molina Healthcare. This pilot program will serve up to 6,000 Members residing in Snohomish County. The program began on January 1, 2005. WMIP is designed to increase the efficiency of the healthcare system by preventing unnecessary hospitalizations, facilitating appropriate placement in nursing homes and reducing inappropriate use of the emergency department. WMIP involves the coordination of medical, mental health and chemical dependency services. When these services are provided through DSHS directly, they are provided by three separate state agencies, with limited case management. DSHS and Molina Healthcare believe patients will experience improved outcomes and a more independent lifestyle by participating in WMIP. ACCESS TO CARE STANDARDS Molina Healthcare is committed to providing timely access to care in a safe and healthy environment for all Members. Access standards have been developed to ensure all Health care services are provided in a timely manner. The PCP or designee must be available to Members 24 hours a day, seven days a week. This access may be by telephone. Appointment and waiting time standards are shown below.

Type of Care Appointment Wait Time Preventive Care Appointment Within 30 days of request Routine Primary Care Within seven days of request Urgent Care Within 24 hours Emergency Care Available by phone 24 hours/seven days a

week After-Hours Care Available by phone 24 hours/seven days a

week Office Waiting Time Should not exceed 30 minutes Mental Health Intake Assessment

Within 10 working days (see How To Refer For Mental Health Services in this section)

Comprehensive Chemical Dependency Assessment and Treatment Services

Provided to injection drug users no later than 14 days after service requested by Member. If Member cannot be placed in treatment within 14 days, interim services must be made available.



COORDINATION OF CARE WMIP involves the coordination of medical, mental health and chemical dependency services. Molina Healthcare created a program for these Members, utilizing Care Coordination Teams (CCT). These teams are comprised of RN and Social Worker Care Coordinators and Care Coordination Specialists who are available to PCPs, specialists, ancillary Providers (DME, Home Health Agencies), pharmacies, Members and Members’ families to assist with coordinating Health care services. Care Coordination is a collaborative process directed toward assessing needs, coordinating resources and creating flexible, cost-effective options for WMIP individuals. WMIP facilitates quality care and individualized treatment plans. The central focus is the Member, with a dedication to providing a resource base of health-care options. The Care Coordination program is designed to ensure communication and coordination of a Member’s care across Provider types and settings for Members who transition among various care settings. Authorization processes and other Molina Healthcare administrative procedures for Healthy Options and Basic Health plans are not changed or affected by the WMIP Care Coordination program. Providers are encouraged to call the Care Coordination team about any WMIP Member whose care needs are complicated or are difficult to satisfy with office-based arrangements alone. Also, Providers may get calls from Care Coordination staff to seek help or alert the Provider to a special need that requires completion of a Referral. HOW TO REFER FOR MENTAL HEALTH SERVICES Molina Healthcare provides WMIP Members with access to any clinically necessary mental health care, except admission to a state psychiatric hospital. Members may be seen by contracted Providers upon self-Referral, Referral by their PCP or by the participating mental health professional. An initial mental health assessment (to include an intake evaluation and up to two follow-up outpatient sessions) will be pre-certified upon request, without need for clinical review. Following the initial assessment, a request for review of clinical necessity and pre-Authorization of services for continuing care can be made. Authorization determinations will be made through individual consideration of clinical needs. Outpatient services will no longer be limited necessarily to a 12 session benefit limit. Pre-certification and pre-Authorization can be obtained by contacting the WMIP Care Coordination team by phone at (800) 936-9647 or fax at (800) 814-2535. Crisis services do not require pre-certification or pre-Authorization. Medication management provided by an MD, DO or ARNP does not require pre-certification or pre-Authorization. HOW TO REFER FOR OUT PATIENT CHEMICAL DEPENDENCY SERVICES WMIP Members may self-refer or be referred by their PCP or a behavioral health Provider for outpatient chemical dependency services to a Molina Healthcare WMIP contracted Provider. Molina Healthcare contracts with several Providers for WMIP outpatient chemical dependency services



Contracted chemical dependency Providers may bill the following codes without obtaining prior Authorization from Molina Healthcare: Code Modifier 96153 HF 96154 HF 96155 HF H0001 HF H0002 HF H0010 HF H0011 HF H2036 HF T1017 HF While prior Authorization is not required, contracted chemical dependency Providers are required to notify Molina Healthcare’s WMIP Care Coordination team by phone at (800) 936-WMIP (9647) or fax at (800) 814-2535 within forty-eight (48) hours of an admission of a WMIP Member. Urinalysis drug screenings are not a covered benefit under WMIP. Molina Healthcare has decided that limited urinalysis drug screenings will be covered as a benefit exception for WMIP, as long as drug screenings are NOT provided solely to fulfill court requirements. Molina Healthcare will reimburse participating chemical dependency Providers for up to two (2) drug screenings per calendar month. The Providers will be responsible for billing Molina Healthcare directly for this service and Molina Healthcare will reimburse the Provider directly. It will be the Provider’s responsibility to reimburse the lab or vendor supplying the service. SERVICE DEFINITION Health care services include diagnostic evaluation, individual and group counseling and case management which are provided through comprehensive, discrete and coordinated programs for individuals diagnosed as chemically dependent in accordance with an individualized treatment plan. Health care services rendered are based on the principles of American Society of Addiction Medicine (ASAM), which provides abstinence based treatment and promotes community support of individuals as they participate in a continuum of care for their addiction. REQUIREMENTS SPECIFIC TO MOLINA HEALTHCARE WMIP MEMBERS In addition to the obligations of Provider Group outlined elsewhere in this Agreement, the Provider Group shall provide the following services for Molina Healthcare WMIP Members:

A. The Provider Group shall participate fully and completely in the Department of Alcohol & Substance Abuse (DASA) Management Information System (TARGET). To assure this capability all Providers must have a functional personal computer using a Windows operating system version ’95c or above that has a connection to the Internet. This computer must also have the Microsoft Internet Explorer program version 5.5 with



service pack2, loaded and operational. The reporting computer must have an operational Universal Bus (USB) port. The Provider Group must have at least one primary data-entry operator and at least one trained backup data operator. Data operators shall have completed the process of securing a high security level digital certificate from the State of Washington Certification Authority (Digital Security Trust) and shall register with DASA for TARGET 2000. The digital certificate is issued to an individual staff member not to an agency. No sharing of digital certificates pass phrases or TARGET 2000 logon information is allowed. The Provider Group shall notify DASA in writing of staff that arrive or depart and need access to TARGET 2000. Computers, which access TARGET 2000, are to be located in secure areas away from general viewing and traffic. The Provider Group must have access to the technical expertise necessary to keep these resources operational. A Provider may enter into a qualified service agreement with another organization to meet these contract reporting requirements. Participants shall include the prompt and orderly submission of all required data completed in detail and submitted in the manner and time frames required.

The Provider Group shall assure that 85% or more of patients discharged from TARGET indicate the discharge form was reviewed or changed. The Provider Group shall also assure that no more that 15% of open cases are reported as delinquent within TARGET. In the event that the Provider Group fails to fulfill either of these expectations, upon notice by Molina Healthcare, the Provider Group shall submit a plan of corrective action with prescribed timelines. If the Provider Group fails to fulfill either of these expectations again during the term of the contract, Molina Healthcare may withhold payment until the situation is corrected. If the third violation occurs during the term of the contract, Molina Healthcare may terminate the contract.

B. The Provider Group shall assure that data related to Molina Healthcare WMIP Members

is entered into the DASA Management Information System (TARGET) by the 10th of each month following the month of service. The Provider Group shall only invoice Molina Healthcare for the service units that have been entered into TARGET.

C. The Provider Group shall assist Members in accessing the transportation broker, if

needed. D. The Provider Group shall secure the required written releases of information from the

Member in accordance with Chapter 388-805 WAC, Health Insurance Portability and Accountability Act (HIPAA), and 42 CFR Part 2 to facilitate open communication between the Provider Group, Molina Healthcare Medical Director or his/her designee, residential Provider and any other community case managers who may be involved with the Member. All written releases of information shall be maintained in the Member’s file.

E. The Provider Group shall notify Molina Healthcare within forty-eight (48) hours of an

admission of a Molina Healthcare WMIP Member.

F. The Provider Group shall cooperate with Molina Healthcare Medical Director or his/her designee for the purposes of care coordination.



G. The Provider Group shall cooperate with all reasonable requests to support Molina Healthcare in evaluation activities deemed appropriate by Molina Healthcare.

H. Utilization of the Patient Placement Criteria of the ASAM is required. The Provider

Group shall be reimbursed for health care services that meet the definition of medical necessity as determined by ASAM Patient Placement Criteria. Aftercare or follow-up services provided solely to fulfill court requirements shall not be reimbursed through this contract. Provider Group may bill Members for non-covered services in accordance with WAC 388-538-095.

I. The Provider Group shall assure that services are designed and delivered in a manner

sensitive to the needs of age, gender, language, cultural, ethnicity, and sexual orientation of participants and their family Members as outlined in WAC 388-805. The Provider Group shall have procedures for coordinating interpreter services and for accessing culturally specific support groups and related materials.

HOW TO ACCESS VISION SERVICES WMIP Members are excluded from March Vision and may self-refer for routine eye exams to any participating optometrist or ophthalmologist. For medical issues, the Member should be referred by their PCP. QUALITY IMPROVEMENT PROGRAMS Molina Healthcare has established a Quality Improvement Program for WMIP (QIP-WMIP). This program provides the structure and key processes that enable the health plan to carry out its commitment to ongoing improvement of care and service, and improvement of the health of its Members. QIP-WMIP assists the organization in achieving these goals. It is an evolving program that is responsive to the changing needs of the health plan’s customers and the standards established by the medical community, regulatory and accrediting bodies. To meet the scope, purpose and goals of the Quality Improvement Program, QI activities are identified that are relevant to this special program. Ongoing measurement and analysis will assist the organization to determine program effectiveness and the need for change. Important areas of focus will include, but are not limited to: coordination of care; appropriateness and follow-through with chemical dependency Referrals; depression management; preventive care rates and satisfaction with the programs. These outcomes and process measurements will be utilized in the 2004 QIP-WMIP Program Evaluation and for further program development. Molina Healthcare assists Members in learning about health risks through education materials and programs. Members receive mailings about how they can lower their risk for preventable diseases through screening and vaccination. General education on how to stay healthy and handle illness is offered through the Molina Healthcare website and can be requested by mail. Information that is available to Members from the Molina Healthcare website or through Molina Healthcare’s Health Education Department includes:

• The risks of smoking • How to manage stress • How to identify depression



• The importance of exercise • How to modify your diet • How to lower your risk for specific disease • How to cope with chronic illness • Setting and reaching health goals • Controlling blood pressure

Molina Healthcare helps Members stay healthy through the following activities:

• Women’s health reminders for breast and cervical cancer • Important general preventive care reminders for Members with chronic disease

(influenza, pneumococcal vaccine, and colorectal screening) • Free and Clear Smoking Cessation Program • 24-hour Nurse Advice Line

Members who have the following chronic conditions receive educational materials and important care reminders. Tools to help them track important care are offered through these programs:

• Diabetes • Asthma • Cardiovascular Disease • Chronic Obstructive Pulmonary Disease • Chronic Kidney Disease • Depression

HOW TO IDENTIFY A WMIP MEMBER AND VERIFY ELIGIBILITY WMIP Members receive an ID card from Molina Healthcare, identifying them as a WMIP Member and the PCP to whom they are assigned. Please see Section 2, for an example of the Molina Healthcare ID card. When a Molina Healthcare Member presents their card, you can verify if they are a WMIP Member by looking at the program line. If the Member is enrolled in WMIP it will state, “Washington Medicaid Integration Partnership.” WMIP Members also receive an ID card from Health and Recovery Services Administration (HRSA) each month. Please see Section 2, for an example of the ID card from HRSA. If a Member presents their HRSA ID card, you can identify them as a Molina Healthcare Member by looking under the HMO column. The entry there will say “MINT” – which stands for Molina Healthcare Integration. Eligibility is determined on a monthly basis. Payment for services rendered is based on eligibility and benefit entitlement. The contractual agreement between Providers and Molina Healthcare places the responsibility for eligibility verification on the Provider of services. Providers who contract with Molina Healthcare may verify a Member’s eligibility and confirm PCP assignment by checking the following:

• HRSA Medical Assistance ID (MAID) card • Molina Healthcare Member ID card • Monthly PCP eligibility listing • Member Services at (800) 869-7165



Providers may also use a Medical Eligibility Verification (MEV) service. Some MEV services provide access to online HRSA Member eligibility data and can be purchased through approved HRSA vendors. MEV services provide eligibility information for billing purposes such as:

• Eligibility status • Plan enrollment and plan name • Medicare enrollment • Availability of other insurance • Program restriction information

HRSA updates the MEV vendor list as new vendors develop MEV services. For more information and a current list of HRSA vendors, please contact HRSA at (800) 562-6188. Providers can also access eligibility information for WMIP Members free of charge using the WAMedWeb online service. In order to access eligibility on the website, you must complete a Washington DSHS HRSA EDI submitter enrollment form. If you have already completed this form but have not registered to use WAMedWeb, you can do so at the following web address: https://wamedweb.acs-inc.com/wa/general/home.do. MEMBER RIGHTS AND RESPONSIBILITIES WMIP Members’ rights and responsibilities mirror those of Healthy Options. Please see Section 3 for additional details. DISENROLLMENT Voluntary Disenrollment: Members may request termination of enrollment from the plan by submitting a written request to HRSA or by calling their enrollment number at (800) 562-3022. Requests for termination of enrollment may be made in order for the Member to return to DSHS fee-for-service. Members whose enrollment is terminated will be prospectively disenrolled. The disenrollment may take one month, and Molina Healthcare staff will work with the Member and Providers to coordinate necessary care during that time. HRSA notifies Molina Healthcare of all terminations. Neither the Provider nor Molina Healthcare may request voluntary disenrollment on behalf of a Member. Involuntary Disenrollment: When a Member becomes ineligible for enrollment due to a change in eligibility status, or if the Member has comparable coverage, HRSA will disenroll the Member and notify Molina Healthcare. Molina Healthcare may request the involuntary termination of a Member for cause by sending a written notice to HRSA. HRSA will approve/disapprove the request for termination within 30 working days of receipt of request. Molina Healthcare must continue to provide medical services to the Member until they are disenrolled. HRSA will not disenroll a Member based solely on an adverse change in the Member’s health status or the cost of his/her health care needs. HRSA may involuntarily terminate the Member’s enrollment when Molina Healthcare has substantiated all of the following in writing:

1. The Member’s behavior is inconsistent with Molina Healthcare’s rules and regulations, such as intentional misconduct.

2. Molina Healthcare has provided a clinically appropriate evaluation to determine whether

there is a treatable condition contributing to the Member’s behavior and such evaluation



either finds no treatable condition to be contributing or, after evaluation and treatment, the Member’s behavior continues to prevent the Provider from safely or prudently providing medical care to the Member.

3. The Member received written notice from Molina Healthcare of its intent to request

disenrollment, unless the requirement for notification has been waived by HRSA because the Member’s conduct presents the threat of imminent harm to others. Molina Healthcare’s notice to the Member must include the following:

a) The Member’s right to use Molina Healthcare’s appeal process to review the request

to terminate the enrollment b) The Member’s right to use the HRSA hearing process

A Member whose enrollment is terminated for any reason, other than incarceration, at any time during the month is entitled to receive covered services at Molina Healthcare’s expense through the end of that month. If the Member is inpatient at an acute care hospital at the time of disenrollment, and the Member was enrolled with Molina Healthcare on the date of admission, Molina Healthcare and its contracted medical groups/IPAs shall be responsible for payment of all covered inpatient facility and professional services from the date of admission through the date of discharge from the hospital.

WMIP LONG-TERM CARE Long-Term Care (LTC) is a comprehensive set of medical, social and rehabilitative services provided by LTC Providers in either a contracted LTC facility or at the Member’s home. Home and community-based services enable some Members to continue living as independently as possible with assistance to meet their physical, medical, social and cognitive needs. When these needs cannot be met in a community-based setting, nursing facility care is available. Types of LTC Providers include:

• Adult Day Care (ADC) • Adult Day Health (ADH) • Adult Family Home (AFH) • Adult Residential Care (ARC) • Assisted Living Facility (ALF) • Assistive Technology • Nursing Services (NS) • Enhanced Adult Residential Care (EARC) • Environmental Modifications • Home-delivered meals • Nurse Consultation Services (NCS) • Nurse Delegation Services (NDS) • Personal Care Services • Personal Emergency Response System (PERS) • Skilled Nursing Facility (SNF)



General LTC Requirements The following section outlines the general definitions and requirements to which all LTC Providers must adhere. If there are more specific requirements which pertain to only certain LTC Providers, they will be outlined under the LTC Provider’s individual section. Definitions

1. Admission Agreement: The written agreement signed by the Member and the AFH, ALF, ARC, or EARC prior to or at the time the Member is admitted to the AFH, ALF, ARC, or EARC and every 24 months thereafter.

2. Adult Protective Services (APS): A program under Chapter 74.34 RCW that authorizes the Department of Social and Health Services (DSHS) to investigate reports of abandonment, abuse, financial exploitation, neglect and self-neglect of vulnerable adults, and to provide protective services and legal remedies to protect vulnerable adults. Reporting is mandatory for all: • Employees of DSHS; • Law enforcement officers; • Social workers; • Professional school personnel; • Individual Providers (defined in RCW 74.34.020 as a person under contract to

provide services in the home under RCW 74.09 or 74.39A.); • Employees or operators of any facility required to be licensed by the department

(boarding home, nursing home, adult family home, soldiers’ home, residential habilitation center);

• Employees of a social service, welfare, mental health, adult day health, adult day care home health, home care, or hospice agency;

• County coroners or medical examiners; • Christian Science practitioners; and • Health care Providers subject to chapter 18.130 RCW. (Includes, but is not limited to:

physicians, physician’s assistants, physical therapists, occupational therapists, nurses, psychologists, podiatrists, dentists, nursing home administrators, optometrists, osteopaths, pharmacists, EMT, paramedics, counselors, naturopaths, nursing assistants, dietitians, massage therapists, radiology technologists, etc.).

3. Community Options Program Entry System (COPES): A DSHS Aging and Disability

Services (ADSA) Medicaid waiver program that provides community based long-term care services to eligible Members.

4. Comprehensive Assessment and Reporting Evaluation (CARE): The documentation of the Member’s needs, abilities, resources, goals and preferences, and level of care requirements obtained in accordance with section 388-72A WAC or its successor.

5. DDD: DSHS Division of Developmental Disabilities.

6. HCS: DSHS Home and Community Services Division.



7. Member Participation: The amount of money, if any, the Provider collects directly from the Member and applies to the cost of the Member’s authorized care.

8. Negotiated Care Plan (or Care Plan): The most recent written plan of care and services to be provided to the Member. The Negotiated Care Plan is negotiated between the Provider and the Member (and/or the Member’s representative) in accordance with Chapter 388-76 WAC.

9. Negotiated Service Agreement (NSA): A written agreement of services negotiated between the Provider and Member and/or the Member’s representative to the maximum extent possible. The family or surrogate decision maker, if applicable, also gives input to the NSA. The NSA recognizes the Member’s capabilities and choices, and defines the division of responsibility in the implementation of the services. The Molina Healthcare Case manager must also approve the NSA.

10. Nurse Delegation Services: To transfer the performance of selected nursing tasks by a licensed registered nurse to a nursing assistant in specific settings as defined in Chapter 246-840 WAC.

11. Nursing Assistant: A nursing assistant registered under RCW 18.88A or a nursing assistant certified under RCW 18.88 A, who provides care to individuals in certified community residential programs for the developmentally disabled, to individuals residing in licensed adult family homes, or to individuals in in-home settings as per RCW 18.88 A.

12. Service Plan: A written plan for long-term care service delivery which identifies ways to meet the Member’s needs with the most appropriate services as described in Chapter WAC 388-71 and/or RCW 74.39A.

13. Unusual Incidents: A change in circumstances or events that concern a Member’s safety or well being. Unusual incidents may include, but not be limited to the following: an increased frequency, intensity, or duration of any medical conditions; adverse reactions to medication; severe behavioral incidents that are unlike the Member’s ordinary behavior; severe injury; hospitalization; running away; physical or verbal abuse to themselves or others.

14. Background Check: The Provider agrees to undergo a criminal history background check

conducted by Molina Healthcare, as required by RCW 43.20A.710. If the Provider has employees or volunteers who will have unsupervised access to Members in the course of performing the work under this Agreement, the Provider will conduct criminal history background checks on those employees. The Provider will also complete a Criminal History Attestation and Release form and attach a roster of current employees or volunteers.



LTC Provider Obligations

1. Background Check: The Provider agrees to undergo a criminal history background check conducted by Molina Healthcare, as required by RCW 43.20A.710. If the Provider has employees or volunteers who will have unsupervised access to Members in the course of performing the work under this Agreement, the Provider will conduct criminal history background checks on those employees.

2. Death of Members: The Provider shall report all deaths of Molina Healthcare Members under the Provider’s care within 24 hours of death, to the Member’s case manager. The Provider shall follow-up with written notification of the Member’s death to the Member’s case manager within seven days.

3. Drug-Free Workplace: The Provider shall not use alcohol and/or illegal drugs in performing the Provider’s duties under this Agreement.

4. Duty to Promote and Protect the Health and Safety of Molina Healthcare Members: The Provider agrees to perform the Provider’s obligations under this Agreement in a manner that does not compromise the health and safety of any Molina Healthcare Member for whom services are provided by the Provider.

5. Duty to Report Suspected Abuse: Provider shall report, in accordance with state law, all instances of suspected abuse, abandonment, neglect and/or exploitation immediately to Adult Protective Services (APS) at (800) 487-0416, TTY (800) 843-8058. To report abuse or neglect of a child, call (866) END HARM. In addition, the Provider shall immediately report all instances of suspected abuse, abandonment, neglect and/or exploitation, to the Complaint Resolution Unit (CRU) at (800) 562-6078 for vulnerable adults living in Adult Family Homes or Boarding Homes. The Provider shall also notify the Member’s Molina Healthcare case manager.

6. Employment with the State: If the Provider accepts employment with the State of Washington, Provider agrees to immediately notify the Molina Healthcare case manager for each Member to whom the Provider is providing services, and notify DSHS. By entering into this Agreement, the Provider certifies and provides assurances that the Provider meets the minimum qualifications described in the Statement of Work, and that Provider has the ability and willingness to carry out the responsibilities outlined in the Service Plan. The Provider shall contact the Member’s Molina Healthcare case manager if at any time there are any concerns about the Provider’s ability to perform those responsibilities. The Provider acknowledges that he/she is in compliance with Chapter 42.52 RCW, Ethics in Public Service, and agrees to comply with Chapter 42.52 RCW throughout the term of this Agreement.

7. Significant Change in Member’s Condition: The Provider agrees to report any significant change in the Member’s condition within 24 hours to the case manager specified in the Member’s Service Plan.

8. Termination Due to Change in Licensee: The Provider shall give all Molina Healthcare Members in the Provider’s facility and Molina Healthcare 30 days prior notice of any proposed change of licensee for the Provider’s facility. This Agreement shall



automatically terminate on the effective date of a change in licensee.

9. Training: The Provider shall participate in training as required by Molina Healthcare, Washington Administrative Code or DSHS.

10. Treatment of Assets Purchased by Provider: All assets (property) purchased or furnished by the Provider are owned by the Provider, and Molina Healthcare waives all claims of ownership to such property.

11. Treatment of Member Assets: Unless otherwise provided in this Agreement, the Provider shall ensure that any adult Member receiving services from the Provider under this Agreement has unrestricted access to the Member’s personal property. The Provider shall not interfere with any adult Member’s ownership, possession, or use of the Member’s personal property. Upon termination of this Agreement, the Provider shall immediately release to the Member and/or the Member’s guardian or custodian all of the Member’s personal property.

Billing and Payment LTC Providers agree to meet the following requirements to obtain payment:

1. The Member has selected the Provider to provide services at the contracted rate

2. The Provider has provided services to the Member which are authorized by Molina Healthcare and included in the Member’s Service Plan

3. The Provider has complied with all applicable laws and regulations Molina Healthcare shall pay the Provider the amount authorized by Molina Healthcare. The Provider accepts the Molina Healthcare payment amount, together with any Member participation amount, as sole and complete payment for the services provided under the Agreement. The Provider agrees to be responsible for collection of the Member’s participation amount (if any) from the Member in the month in which services are provided. Molina Healthcare shall not pay the Provider when:

1. The Member on whose behalf payment is made is no longer eligible for the Provider’s services

2. The Provider ceases to meet service Provider minimum qualifications as defined in Chapter 70.128 RCW and Chapter 388-76 WAC, or successor or replacement statute or regulations

3. Molina Healthcare has terminated the Agreement with Provider

4. The Provider fails to provide services as authorized in the Member’s Service Plan or

Negotiated Care Plan



5. Authorized services are not provided to Members, or for services provided which are not authorized or provided in accordance with the Statement of Work

If the Agreement is terminated for any reason, Molina Healthcare shall pay only for those services authorized and provided through the date of termination. LTC Insurance Requirements Adult Residential Care Provider, Enhanced Adult Residential Care Provider and Assisted Living Facility Provider:

1. Professional Liability Insurance Provider shall maintain Professional Liability Insurance or Errors & Omissions Insurance, including coverage for losses caused by errors and omissions, with the following minimum limits: Each Occurrence - $1,000,000; Aggregate - $2,000,000

2. General Liability Insurance Provider shall maintain Commercial General Liability Insurance, or Business Liability Insurance, including coverage for bodily injury, property damage, and contractual liability, with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000

The policy shall include liability arising out of premises, operations, independent contractors, products-completed operations, personal injury, advertising injury, and liability assumed under an insured contract. In lieu of general liability insurance mentioned above, if the Provider is a sole proprietor with less than three contracts, the Provider may choose one of the following three general Liability policies but only if attached to a professional liability policy, and if selected the policy shall be maintained for the life of the Agreement. • Supplemental Liability Insurance

Including coverage for bodily injury and property damage that will cover the Provider wherever the service is performed with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000

• Workplace Liability Insurance

Including coverage for bodily injury and property damage that provides coverage wherever the service is performed with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000

• Premises Liability Insurance Provide services only at their recognized place of business, including coverage for bodily injury, property damage with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000

3. Employees and Volunteers Insurance required of the Provider under the Agreement shall include coverage for the acts and omissions of the Provider’s employees and volunteers. In addition, the Provider



shall ensure that all employees and volunteers who use vehicles to transport clients or deliver services have personal automobile insurance and current driver’s licenses.

4. Subcontractors The Provider shall ensure that all subcontractors have and maintain insurance with the same types and limits of coverage as required of the Provider under this Agreement.

5. Insurers The Provider shall obtain insurance from insurance companies identified as an admitted insurer/carrier in the State of Washington, with a Best’s Reports’ rating of B++, Class VII, or better. Surplus Lines Insurance companies will have a rating of A-, Class VII, or better.

Adult Day Care Provider:

1. Commercial General Liability Insurance The Provider shall maintain Commercial General Liability Insurance, including coverage for bodily injury, property damage, and Contractual liability, with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $1,000,000 The policy shall include liability arising out of premises, operations, independent contractors, products-completed, operations, personal injury, advertising injury, and liability assumed under an insured Agreement, including tort liability of another assumed in a business Agreement.

2. Employees and Volunteers Insurance required of the Provider under the Agreement shall include coverage for the acts and omissions of the Provider’s employees and volunteers. In addition, the Provider shall ensure that all employees and volunteers who use vehicles to transport Members or deliver services have personal automobile insurance and current driver’s licenses.

3. Subcontractors The Provider shall ensure that all subcontractors have and maintain insurance with the same types and limits of coverage as required of the Provider under the Agreement.

4. Separation of Insureds All insurance policies shall include coverage for cross liability and contain a Separation of Insureds provision.

5. Insurers The Provider shall obtain insurance from insurance companies authorized to do business within the State of Washington, with a Best’s Reports rating of A-, Class VII or better. Any exceptions must be approved by Molina Healthcare Credentialing department. Exceptions include placement with a Surplus Lines insurer or an insurer with a rating lower than A-, ClassVII.



Adult Family Home Provider: 1. The Adult Family Home (AFH) shall possess homeowner’s, renter’s and/or General

Liability Insurance in appropriate amounts.

2. Worker’s Compensation The Provider shall comply with all applicable Worker’s Compensation, occupational disease, and occupational health and safety laws and regulations. Molina Healthcare shall not be held responsible for claims filed for Worker’s Compensation under RCW51 by the Provider or its employees under such laws and regulations.

3. Employees and Volunteers Insurance required of the Provider under the Agreement shall include coverage for the acts and omissions of the Provider’s employees and volunteers. In addition, the Provider shall ensure that all employees and volunteers who use vehicles to transport Members or deliver services have personal automobile insurance and current driver’s licenses.



6. Insurers The AFH shall obtain insurance from insurance companies identified as an admitted insurer/carrier in the State of Washington, with a Best’s Reports rating of B++, Class VII, or better. Surplus Lines insurance companies will have a rating of A-, Class VII, or better.

Nurse Delegation Services, Direct Nursing Services and Nurse Consultation Services Providers:

1. Professional Liability Insurance The Provider shall maintain Professional Liability Insurance or Errors & Omissions Insurance, including coverage for losses caused by errors and omissions, with the following minimum limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000

2. Worker’s Compensation The Provider shall comply with all applicable Worker’s Compensation, occupational disease, and occupational health and safety laws and regulations.

3. Employees and Volunteers Insurance required of the Provider under the Agreement shall include coverage for the acts and omissions of the Provider’s employees and volunteers. In addition, the Provider shall ensure that all employees and volunteers who use vehicles to transport Members or deliver services have personal automobile insurance and current driver’s



licenses.



6. Insurers The Provider shall obtain insurance from insurance companies identified as an admitted insurer/carrier in the State of Washington, with a Best’s Reports rating of B++, Class VII, or better. Surplus Lines insurance companies will have a rating of A-, Class VII, or better.

Adult Day Care & Adult Day Health Adult Day Care (ADC) is a supervised daytime program where core services are provided to Members who meet the eligibility requirements under WAC 388-71-0708 and do not have medical or disabling conditions that require the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the Member’s physician. Adult Day Health (ADH) is a supervised daytime program providing skilled nursing and rehabilitative services in addition to core services to Members who meet the eligibility requirement under WAC 388-71-0710. Statement of Work The ADC and ADH shall:

1. Meet the Adult Day Care or Adult Day Health requirements in WAC 388-71-0702 through 388-71-0776.

2. ADC shall provide adult day care services in accordance with WAC 388-71-0702 through 388-71-0776. The Provider shall provide core services appropriate for adults with medical or disabling conditions and do not require the direct intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the Member’s physician. Core services are: a. Personal Care b. Social services with consultation from a social worker c. Routine health monitoring with consultation from a registered nurse d. General therapeutic activities an unlicensed person can provide or a licensed person

can provide with or without a physician’s order e. General health education an unlicensed person can provide or a licensed person can

provide with or without a physician’s order f. Nutritional meals and snacks g. Supervision and/or protection h. Assistance with arranging transportation to and from the program; and



i. First aid and provisions for obtaining or providing care in an emergency

3. ADH must offer and provide onsite all core services as described in WAC 388-71-0704 and paragraphs 2a through 2i above. In addition, the following services must be provided: a. Skilled nursing services other than routine health monitoring with nurse consultation; b. At least one of the following skilled therapy services: physical therapy, occupational

therapy, or speech-language pathology or audiology, as defined under Chapters 18.74, 18.59 and 18.35 RCW;

c. Psychological or counseling services, including assessing for psycho-social therapy needs, dementia, abuse or neglect, and alcohol or drug abuse; making appropriate Referrals; and providing brief, intermittent supportive counseling.

Obligations Molina Healthcare shall provide to ADC and ADH: (1) a copy of the relevant terms of the Member’s Service Plan describing the services to be performed by the ADC or ADH; and (2) any supplements or amendments to those Service Plan terms. ADC or ADH agrees to perform such Adult Day Care or Adult Day Health Services throughout the period of this Agreement. Any and all terms provided to ADC and ADH shall be incorporated into this Agreement by this reference. The ADC and ADH shall provide two week’s advance written notice to the Member, the Member’s legal representative, Molina Healthcare and any other party who has requested notice, prior to terminating adult day care or adult day health services.

Adult Family Home Adult Family Home (AFH) is a residential home in which a person or persons provide personal care, special care, room, and board for more than one but not more than six adults who are unrelated by blood or marriage to the person or persons providing the services. Statement of Work The AFH shall:

1. Provide services to each Member as specified in the Member’s authorized Service Plan and Negotiated Care Plan. The most recent Service Plan and Negotiated Care Plan for any Member placed by Molina Healthcare in the AFH are incorporated in this Agreement by reference.

2. Involve the Member’s Molina Healthcare case manager in the development of the Negotiated Care Plan and shall provide the case manager with a copy of any changes in the Care Plan.

3. Perform all work under this Agreement, the Service Plan and the Negotiated Care Plan in accordance with Chapters 70.128 and 70.129 RCW and Chapter 388-76 WAC, or successor or replacement statutes or regulations.



Billing and Payment AFHs shall be paid monthly for services provided to Molina Healthcare Members in accordance with their Agreement, less Member participation. The AFH must disclose all supplemental or additional charges in the Admission Agreement. The AFH shall refund to the Member the amount prepaid for care of that Member on a prorated basis in the event the Member moves out of the home before the end of the month. Molina Healthcare shall not pay the Provider when the Member is absent (not due to admission to a hospital or nursing facility) from the AFH in excess of 72 hours, unless the absence is justified in writing and placed in the Member’s file maintained by the AFH. Molina Healthcare shall not pay the AFH or Molina Healthcare shall reduce the amount of the payment to the AFH when the Member temporarily is admitted to a hospital or nursing facility and the AFH must hold the Member’s bed for the Member’s return in accordance with WAC 388-105-0045 or its successor. Credentialing The AFH acknowledges and certifies as follows:

1. The AFH has obtained and reviewed the DSHS AFH licensing laws and regulations and shall comply with the requirements set forth therein, and with all supplemental, successor or replacement requirements.

2. The AFH certifies and assures Molina Healthcare that the AFH is a licensed adult family home Provider and meets the minimum qualifications for adult family home Providers as described under Chapter 388-76 WAC.

3. The AFH shall not accept any Molina Healthcare Member or other placement in excess of the AFH’s licensed capacity as stated in the AFH’s AFH license.

4. The AFH shall not accept any Molina Healthcare Member for placement in the AFH for which the AFH has not received the Member’s Molina Healthcare-authorized Service Plan.

5. The AFH’s licensed facility capacity shall be in accordance with the AFH’s current AFH license, but may increase or decrease in accordance with the AFH’s AFH license during the term of this Agreement without the necessity of amending this Agreement. This Agreement shall be null and void immediately upon the effective date of revocation of the AFH’s AFH license, or when the AFH’s AFH license is no longer valid.

Placement

1. Immediately upon arranging with the AFH for placement of a Molina Healthcare Member in the AFH, Molina Healthcare shall forward to the AFH Authorization and the Member’s Comprehensive Assessment and Reporting Evaluation and most recent Service



Plan.

2. Upon placement of a Molina Healthcare Member in the AFH, the AFH shall prepare a Member file, which shall be the property of Molina Healthcare, and shall contain the documents provided by DSHS and all other documents required to be maintained by the Agreement or by Molina Healthcare.

3. The AFH shall notify the Molina Healthcare case manager in writing when a Member requires more care than the AFH can provide. In addition, the AFH shall notify the Molina Healthcare case manager when there has been a significant change for better or worse in the condition of the Member.

4. When a Member is absent from the AFH for more than 72 hours for other than medical reasons, the AFH shall enter written justification of such absence in the Member’s file.

5. Social leave is limited to no more than 18 days per calendar year. Social leave is defined as leave that is for recreational or socialization purposes, not for medical, therapeutic or recuperative purposes. The AFH shall notify the case manager within one working day when a Molina Healthcare Member takes social leave.

Adult Residential Care Adult Residential Care (ARC) provides a package of services including personal care services that are to be provided by the ARC in accordance with parts I and IV of Chapter 388-110 WAC. Statement of Work The ARC shall comply with all requirements of Chapter 18.20 RCW, Boarding Homes and Chapter 388-78A WAC, Boarding Homes. The ARC shall provide services as required in Chapter 388-100 WAC to each Member placed in the ARC facility as specified in the Member’s NSA and authorized by Molina Healthcare. The NSA for any Member placed by Molina Healthcare in the ARC facility is incorporated in this Agreement by reference. All work performed under this Agreement and any NSA shall be performed in accordance with Chapter 70.129 RCW and Chapter 388-110 WAC. Credentialing The ARC acknowledges and certifies as follows:

1. The ARC has received a copy of DSHS’s Adult Residential Care licensing packet and shall comply with the requirements set forth therein, and with all supplemental, successor or replacement requirements.

2. The ARC shall not accept any Molina Healthcare Members or other placement in excess of the ARC’s licensed capacity as stated in the ARC’s DSHS boarding home license.

3. The ARC shall complete a NSA for each Molina Healthcare Member placed in the ARC facility within 30 days of placement.



Assisted Living Facility Assisted Living Facilities (ALF) provide a package of services including personal care and limited nursing services, and housing in a private apartment-like unit, that are to be provided by the ALF in accordance with parts I and II of Chapter 388-110 WAC. Statement of Work The ALF shall comply with all requirements of Chapter 18.20 RCW, Boarding Homes and Chapter 388-78AWAC, Boarding Homes. The ALF shall provide services as required in Chapter 388-110 WAC to each Member placed in the ALF as specified in the Member’s NSA and authorized by Molina Healthcare. The NSA for any Member placed by Molina Healthcare in the ALF is incorporated in this Agreement by reference. All work performed under this agreement and any NSA shall be performed in accordance with Chapter 70.129 RCW and Chapter 388-110 WAC. Credentialing The ALF acknowledges and certifies as follows:

1. The ALF has received a copy of the DSHS Assisted Living Facility licensing packet and shall comply with the requirements set forth therein, and with all supplemental, successor or replacement requirements.

2. The ALF shall not accept any Molina Healthcare Member or other placement in excess of the ALF’s licensed capacity as stated in the ALF’s DSHS boarding home license.

3. The ALF shall complete a NSA for each Molina Healthcare Member placed in the ALF facility within 30 days of placement.

Enhanced Adult Residential Care Enhanced Adult Residential Care (EARC) provides a package of services including personal care and limited nursing services to be provided by the EARC in accordance with parts I and III of Chapter 388.110 WAC. Statement of Work The EARC shall comply with all requirements of Chapter 18.20 RCW, Boarding Homes and Chapter 388-78A WAC, Boarding Homes. The EARC shall provide services as required in Chapter 388-110 WAC to each Member placed in the EARC facility, as specified in the Member’s NSA and Authorized by Molina Healthcare. The NSA for any Member placed by Molina Healthcare in the EARC facility is incorporated in this Agreement by reference. All work performed under this Agreement and any NSA shall be performed in accordance with Chapter 70.129 RCW and Chapter 388-110 WAC.



Credentialing EARC acknowledges and certifies as follows:

1. The EARC has received a copy of the licensing packet and shall comply with the requirements set forth therein, and with all supplemental, successor or replacement requirements.

2. The EARC shall not accept any Molina Healthcare Member or other placement in excess of the EARC’s licensed capacity as stated in the EARC’s DSHS boarding home license.

3. The EARC shall complete an NSA for each Molina Healthcare Member placed in the EARC facility within 30 days of placement.

Personal Care Services - Home Care Agencies Personal Care Services (PCS) are those services provided for Members functionally unable to perform all or part of their personal care tasks, or for Members who cannot perform the tasks without specific instructions. Personal care services do not include assistance with tasks performed by a licensed health professional. Personal care services may include physical assistance, and/or prompting and supervising the enrollee in performance of direct personal care tasks and household tasks. Statement of Work Services will be provided in the Member’s home unless Authorized and written into the Member’s Authorization by Molina Healthcare. The Vendor may not modify in any way the type and amount of Authorized service without prior approval from Molina Healthcare. Home Care Agencies must ensure each home care aide will be oriented to and have access to a copy of each Member’s assessment details, in addition to any Service Plan created by Molina Healthcare.

Home care agencies providing a one-time visit for a Member may provide the following written documentation in lieu of the home care plan of care and Member record requirements in WAC 246-335-110 (1)(c):

1. Member name, age, current address, and phone number 2. Confirmation the Member was provided a written bill of rights WAC 246-335-075 3. Member consent for services to be provided 4. Documentation of services provided

Personal care tasks with which Home Care Agencies shall provide assistance include, but are not limited to:

1. Assistance with walking/locomotion 2. Bathing 3. Bed mobility, i.e. repositioning enrollee in chair or bed 4. Body care 5. Dressing 6. Eating



7. Essential shopping 8. Housework 9. Laundry 10. Meal preparation 11. Personal hygiene 12. Self-medication administration 13. Supervision 14. Toileting 15. Transfer, i.e. assisting enrollee to move from bed to chair, etc. 16. Travel to medical services 17. Wood supply

Credentialing The Agency must be licensed as a Home Care Agency, or Home Health Agency, as defined in RCW 70.127 and WAC 246-335. The Home Care Agency acknowledges and certifies as follows:

1. Agency will verify all prospective PCS Providers satisfy the minimum qualifications for Personal Care Providers in home settings, as described in WAC 388-71 including, but not limited to, the items listed below before they provide the following services to enrollees:

a. Verify the prospective PCS Provider is over 18 years of age. b. Verify and collect information required by the WAC, including WAC 388-71-

0510. c. Verify the prospective PCS Provider’s Authorization to work in the United States. d. Complete background checks. If the prospective PCS Provider has lived in State

for less than three years, the background check shall also include fingerprinting.

2. No PCS Provider will perform any task requiring a registration, certificate or license unless he or she is registered, certified or licensed to do so; is a Member of the Member’s immediate family; or is performing self-directed health care tasks. RCW 18.79, 19.88 and 74.39 provide more information about regulations related to nursing care, Registered Nurse Delegation and self-directed health care tasks.

Nurse Delegation Services (NDS), Direct Nursing Services (DNS), Nurse Consultation Services (NCS) The Nurse Delegation Program provides for the training and supervision of a nursing assistant to perform client-specific skilled nursing tasks under the direction and ongoing supervision of a registered nurse delegator (RND). Direct Nursing Services are services are provided by a registered professional nurse, or licensed practical or vocational nurse under the supervision of a registered nurse licensed to practice in the State of Washington. Services may be provided in the Member’s home or in an Adult Family Home setting. Statement of Work NDS - As Authorized by Molina Healthcare and in accordance with RCW 18.79 and WAC 246-840-910 to 970, the RND shall perform a physical assessment of the Member's needs and be responsible for ongoing supervision of the nursing assistant, the Member's condition and the



delegated skilled nursing task(s); and for all related and required documentation, teaching, delegation and supervision activities. The trained nursing assistant shall provide client-specific care in the Member's home setting, and shall perform the task according to the RND’s instruction. The nursing assistant shall not perform those tasks prohibited in RCW 18.88A.210 and shall successfully complete the 9-hour class, Nurse Delegation for Nursing Assistants, prior to performing a delegated task. The RND shall:

1. Determine the competency of each nursing assistant to perform the specific task for a specific client;

2. Evaluate the appropriateness of delegating the task(s); 3. Supervise the actions of the person performing the delegated task; 4. Delegate only those tasks that are within the registered nurse’s scope of practice; 5. Re-assess the Member's physical condition a minimum of once every 90 days to verify

the Member's condition remains stable and predictable per WAC 246-840-910 to 970, and that delegation may continue.

Before commencing any specific nursing care tasks, the nursing assistant must (a) provide to the delegating nurse a certificate of completion issued by DSHS indicating the completion of basic core nurse delegation training, (b) be regulated by the department of health pursuant to RCW Chapter 18.88a, subject to the uniform disciplinary act under RCW Chapter 18.130, and (c) meet any additional training requirements identified by the nursing care quality assurance commission. Exceptions to these training requirements must adhere to RCW 18.79.260(3)(e)(v). DNS - As Authorized by Molina Healthcare the DNS shall administer drugs, injections, inoculations, treatments and tests to the Member in accordance with RCW 18.79. In addition, the DNS shall document, in the Member’s record, all direct nursing services provided by the DNS to the Member. Ensure that the Member’s record is located at the Member’s place of residence. DNS is required to maintain a copy of the Member’s record. NCS - As Authorized by Molina Healthcare and in accordance with RCW 18.79, the NC shall assess the Member’s health-related needs and consult with Molina Healthcare staff on service planning; complete all related and required documentation and teaching and coordination activities. Credentialing Licensing Requirements The NDS, DNS, NCS shall maintain all necessary licenses, registrations, and certifications as required by RCW 18.79.260, 18.88A.210 and WAC 246.840. Licenses, registrations and certifications must remain in good standing without any substantiated complaints or sanctions during the period of performance of this Agreement. Minimum Qualifications The NDS, DNS, NCS shall:

1. Possess a valid Washington State Registered Nurse license without any limitations or restrictions

2. Have two years of experience as a registered nurse 3. Have one year of experience demonstrating skill and experience in client assessment,

documentation of assessments and development of nursing care plans



4. Have demonstrated leadership, teaching experience, and the ability to work independently

5. Have demonstrated excellent oral and written communication skills 6. Maintain current Professional Liability insurance coverage

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