WSR 11-14-053

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed June 29, 2011, 12:20 p.m. , effective July 30, 2011 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The new rules: (1) Support recently filed rules that meet the Governor's Executive Order 10-06 exemption criteria for rule making because they are necessary to manage budget shortfalls, maintain fund solvency, or for revenue generating activities for fiscal year ending June 30, 2011; (2) assure consistency with how terms are defined and used throughout department medical assistance program rules; (3) meet the requirements of 2E2SHB 1738, the legislation that authorizes the medical purchasing administration and the health care authority (HCA) to merge into one agency effective July 1, 2011, by changing any references to "the department" (DSHS) to "the agency or the agency's designee"; and (4) place defined words and phrases into their own alpha sections which allows readers to locate a definition quickly.

Citation of Existing Rules Affected by this Order: Amending WAC 388-500-0005.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: 2E2SHB 1738.

Adopted under notice filed as WSR 11-07-077 on March 22, 2011.

Changes Other than Editing from Proposed to Adopted Version: Added the following cross-references (underlined) to definitions in chapter 388-500 WAC:

WAC 388-500-0020 "Couple" See "spouse." in WAC 388-500-0100.

WAC 388-500-0050 "Ineligible spouse" See "spouse." in WAC 388-500-0100.

WAC 388-500-0050 "Institution for mental diseases (IMD)" See "institution." in this section.

WAC 388-500-0050 "Institutionalized spouse" See "spouse." in WAC 388-500-0100.

WAC 388-500-0050 "Intermediate care facility for the mentally retarded (ICF/MR)" See "institution." in this section.

WAC 388-500-0070 "Medical institution" See "institution." in WAC 388-500-0050.

WAC 388-500-0075 "Nonapplying spouse" See "spouse." in WAC 388-500-0100.

WAC 388-500-0075 "Noncovered service" See "covered service." in WAC 388-500-0020.

WAC 388-500-0075 "Nursing facility" See "institution." in WAC 388-500-0050.

WAC 388-500-0085 "Public institution" See "Institution." in WAC 388-500-0050.

Changed "the department" (DSHS) (strikethrough) to "the agency" (HCA) or "the agency's designee" (underlined):

WAC 388-500-0005 Chapter 388-500 WAC, other department agency or agency's designee WAC, ... other department agency or agency's designee WAC, the definition in the specific WAC prevails.

WAC 388-500-0010 "Authorization" means the department's agency's or the agency's designee's determinations ... to the department's agency's or the agency's designee's decision ...

WAC 388-500-0015 "By report (BR)" means ... the department agency or the agency's designee determines ... in the department's agency's or the agency's designee(s) published fee schedules.

WAC 388-500-0025 "Delayed certification" means department agency or the agency's designee approval ...

WAC 388-500-0025 "Dental consultant" means ... by the department agency or the agency's designee.

WAC 388-500-0030 "Early and periodic screening, diagnosis and treatment (EPSDT)" is a ... for any department agency healthcare program.

WAC 388-500-0030 "Expedited prior authorization (EPA)" means ... to indicate to the department agency or the agency's designee which acceptable ... or department agency or agency's designee-defined criteria ...

WAC 388-500-0035 "Fee-for-service (FSS)" The general payment method the department agency or agency's designee uses ... under the department's agency's prepaid managed care programs.

WAC 388-500-0045 "Health maintenance organization (HMO)" means ... the department agency on a ...

WAC 388-500-0050 "Institution" ... (3) "Medical institution" (b)(i) "Hospice care center" - an entity ... and approved by the department agency or the agency's designee to be ...

WAC 388-500-0050 "Institution" ... (3) "Medical institution" (b)(v) "Psychiatric residential treatment facility (PRTF)" -- a nonhospital ... by the department agency or the agency's designee to provide ...

WAC 388-500-0050 "Institution" ... (3) "Medical institution" (c) medical institutions do not ... by the department agency or the agency's designee as adult family homes ...

WAC 388-500-0070 "Medical assistance" for the purposes of ... by the department agency or the agency's designee that provide ...

WAC 388-500-0070 "Medical assistance administration (MAA)" is the former ... now administered by the agency, formerly the medicaid purchasing administration (MPA), of formerly the health and recovery services administration (HRSA).

WAC 388-500-0075 "NCCI edit" is a ... state regulations, department agency or the agency's designee fee schedules ... The department agency or the agency's designee has the final decision ... NCCI standards or department agency or agency's designee policy.

WAC 388-500-0085 "Prior authorization" is the requirement ... the department's agency's or the agency's designee's approval to render ... The department's agency's or the agency's designee's approval ...

WAC 388-500-0085 "Provider" means ... (1) Has signed a...with the department agency or the agency's designee, and is ... (2) Has authorization ... with the department agency or the agency's designee to provide ...

WAC 388-500-0095 "Regional support network (RSN)" means ...which the department agency or the agency's designee contracts for ...

WAC 388-500-0100 "Spenddown" is a term used ... by the department agency.

WAC 388-500-0105 "Third party" means and entity other than the department agency or the agency's designee that is ...

Other changes:

WAC 388-500-0010 "Agency" means the Washington state health care authority, created pursuant to chapter 41.05 RCW.

WAC 388-500-0020 "Covered service" is a healthcare service contained within a "service category," that is included in a medical assistance benefits package as described in WAC 388-501-0060, included in the medical assistance program's benefit package. For conditions of payment, see WAC 388-501-0050(5). A noncovered service is a specific healthcare service (for example, cosmetic surgery), contained within a service category that is included in a medical assistance benefits package, for which the agency requires an approved exception to rule (ETR) (see WAC 388-501-0160). A noncovered service is not an excluded service (see WAC 388-501-0060).

WAC 388-500-0030 "Emergency medical expense requirement (EMER)" See WAC 388-865-0217(3).

WAC 388-500-0030 "Evidenced-based medicine (EBM)" means the applications of a set of principles ... and beneficial when making: (1) pPopulation-based healthcare coverage policies (see WAC 388-501-0055 describes how the department determines coverage of services for its healthcare programs by using evidence and criteria based on health technology assessments), or; and (2) iIndividual medical necessity decisions (see WAC 388-501-0165 describes how the department uses the best evidence available to determine if a service is medically necessary as defined in WAC 388-500-0030).

WAC 388-500-0030 "Extended care services" means nursing and rehabilitative care in a skilled nursing facility provided to a recently hospitalized medicare patient needing relatively short-term skilled nursing and rehabilitative care in a skilled nursing facility.

WAC 388-500-0045 Move definition of "Healthcare Professional" to after the definition of "Health maintenance organization (HMO)".

WAC 388-500-0045 Add: "Healthcare service category" means a grouping of healthcare services listed in the table in WAC 388-501-0060. A healthcare service category is included or excluded depending on the client's medical assistance benefits package.

WAC 388-500-0070 "Medical facility" means a medical institution or a medical clinic that provides healthcare services. A medical clinic does not meet the criteria to be considered a medical institution (see "medical institution").

WAC 388-500-0075 "Noncovered service(s)" means a specific healthcare service(s) or item(s) the department has determined it will not cover or pay for any client under any medical assistance program. Noncovered services are identified in WAC 388-50-0070 and in specific healthcare program rules See "covered service" in WAC 388-500-0020.

WAC 388-500-0100 "Scope of healthcare service categories" are the groupings of healthcare services listed in the table in WAC 388-501-0060 that are available under each medical assistance program's benefits package.

WAC 388-500-0100 "State supplemental payment (SSP)" is a state funded cash benefit for certain individuals who are either recipients of the Title XVI supplemental security income (SSI) program or who are clients of the division of developmental disabilities. The SSP allotment for Washington state is a fixed amount of $28.9 million and must be shared between all individuals who fall into one of the groups listed below. The amount of the SSP may vary each year depending on the number of individuals who qualify. The following groups are eligible for an SSP:

(1) Mandatory SSP group--SSP made to a mandatory income level client (MIL) who was grandfathered into the SSI program. To be eligible in this group, an individual must have been receiving cash assistance in December 1973 under the department's former old age assistance program or aid to the blind and disability assistance. Individuals in this group receive an SSP to bring their income to the level they received prior to the implementation of the SSI program in 1973.

(2) Optional SSP group--SSP made to any of the following:

(a) An individual who receives SSI and has an ineligible spouse.

(b) An individual who receives SSI based on meeting the age criteria of sixty-five or older.

(c) An individual who receives SSI based on blindness.

(d) An individual who has been determined eligible for SSP by the division of developmental disabilities.

(e) An individual who is eligible for SSI as a foster child as described in WAC 388-474-0012.

WAC 388-500-0100 "Supplementary payment (SSP)" means the state money payment to a person receiving benefits under Title XVI, or who would, but for the person's income, be eligible for such benefits, as assistance based on need in supplementation of SSI benefits. This payment includes: "Mandatory state supplement" - the state money payment to a person who, for December 1973, was a client receiving cash assistance under the department's former programs of old age assistance, aid to the blind and disability assistance; and "Optional state supplement" - the elective state money payment to a person eligible for SSI benefits or who, except for the level of the person's income, would be eligible for SSI benefits.

A final cost-benefit analysis is available by contacting Gail Kreiger, P.O. Box 45500, Olympia, WA 98504-5500, phone (360) 725-1949, fax (360) 725-9152, e-mail gail.kreiger@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 18, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 18, Amended 1, Repealed 0.

Date Adopted: June 24, 2011.

Katherine I. Vasquez

Rules Coordinator

Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 11-15 issue of the Register.

Washington State Code Reviser's Office