WSR 13-16-006
PERMANENT RULES
HEALTH CARE AUTHORITY
(Medicaid Program)
[Filed July 25, 2013, 9:49 a.m., effective August 25, 2013]
Effective Date of Rule: Thirty-one days after filing.
Purpose: Amendments to these sections are necessary to begin paying providers under fee-for-service for air ambulance services provided to clients enrolled in agency-contracted managed care organizations. These payments are no longer the responsibility of the prepaid managed care plans. This change is in accordance with the agency's state plan.
Citation of Existing Rules Affected by this Order: Amending WAC 182-546-0150 and 182-546-0400.
Statutory Authority for Adoption: RCW 41.05.021.
Adopted under notice filed as WSR 13-13-071 on June 18, 2013.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.
Date Adopted: June 25, 2013.
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-546-0150 Client eligibility for ambulance transportation.
(1) Except for clients in the Family Planning Only and TAKE CHARGE programs, ((MAA)) fee-for-service clients are eligible for ambulance transportation to ((MAA)) covered services with the following limitations:
(a) Clients in the following programs are eligible for ambulance services within Washington state or bordering cities only, as designated in WAC ((388-501-0175)) 182-501-0175:
(i) ((General assistance-unemployable (GA-U))) Medical care services (MCS) as described in WAC 182-508-0005;
(ii) ((General assistance-expedited medical (GA-X);
(iii) General assistance-pregnancy (GA-S);
(iv))) Alcoholism and Drug Addiction Treatment and Support Act (ADATSA) as described in WAC 182-508-0320;
(((v) Emergency medical programs, including)) (iii) Alien emergency medical (AEM)((;
(vi) LCP-MNP emergency medical only; and
(vii) State Children's Health Insurance Program (CHIP) when the client is not enrolled in a managed care plan)) services as described in chapter 182-507 WAC.
(b) Clients in the categorically needy/qualified medicare beneficiary (CN/QMB) and medically needy/qualified medicare beneficiary (MN/QMB) programs are covered by medicare and medicaid, with the payment limitations described in WAC ((388-546-0400(5))) 182-546-0400(5).
(2) Clients enrolled in an ((MAA)) agency-contracted managed care ((plan receive all)) organization (MCO) must coordinate:
(a) Ground ambulance services through their designated ((plan)) MCO, subject to the ((plan's)) MCO coverage((s)) and limitations; and
(b) Air ambulance services through the agency under fee-for-service, subject to the coverage and limitations within this chapter.
(3) Clients enrolled in ((MAA's)) the agency's primary care case management (PCCM) program are eligible for ambulance services that are emergency medical services or that are approved by the PCCM in accordance with ((MAA)) the agency's requirements. ((MAA)) The agency pays for covered services for these clients according to ((MAA's)) the agency's published ((billing instructions)) medicaid provider guides and provider notices.
(4) Clients under the Involuntary Treatment Act (ITA) are not eligible for ambulance transportation coverage outside the state of Washington. This exclusion from coverage applies to individuals who are being detained involuntarily for mental health treatment and being transported to or from bordering cities. See also WAC ((388-546-4000)) 182-546-4000.
(5) See WAC ((388-546-0800)) 182-546-0800 and ((388-546-2500)) 182-546-2500 for additional limitations on out-of-state coverage and coverage for clients with other insurance.
(6) The agency does not pay for ambulance services for jail inmates and persons living in a correctional facility ((are not eligible for MAA ambulance coverage)). See WAC ((388-503-0505(5))) 182-503-0505(5).
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-546-0400 General limitations on payment for ambulance services.
(1) In accordance with WAC ((388-502-0100(8))) 182-502-0100(8), the ((medical assistance administration (MAA))) agency pays providers the lesser of the provider's usual and customary charges or the maximum allowable rate established by ((MAA)) the agency. ((MAA's)) The agency's fee schedule payment for ambulance services includes a base rate or lift-off fee plus mileage.
(2) ((MAA)) The agency:
(a) Does not pay providers under fee-for-service for ground ambulance services provided to a client who is enrolled in an ((MAA)) agency-contracted managed care ((plan)) organization (MCO). Payment in such cases is the responsibility of the ((prepaid managed care plan)) client's agency-contracted MCO;
(b) Pays providers under fee-for-service for air ambulance services provided to a client who is enrolled in an agency-contracted MCO.
(3) ((MAA)) The agency does not pay providers for mileage incurred traveling to the point of pickup or any other distances traveled when the client is not on board the ambulance. ((MAA)) The agency pays for loaded mileage only as follows:
(a) ((MAA)) The agency pays ground ambulance providers for the actual mileage incurred for covered trips by paying from the client's point of pickup to the point of destination.
(b) ((MAA)) The agency pays air ambulance providers for the statute miles incurred for covered trips by paying from the client's point of pickup to the point of destination.
(4) ((MAA)) The agency does not pay for ambulance services if:
(a) The client is not transported;
(b) The client is transported but not to an appropriate treatment facility; or
(c) The client dies before the ambulance trip begins (see the single exception for ground ambulance providers at WAC ((388-546-0500(2))) 182-546-0500(2)).
(5) For clients in the categorically needy/qualified medicare beneficiary (CN/QMB) and medically needy/qualified medicare beneficiary (MN/QMB) programs ((MAA's)) the agency's payment is as follows:
(a) If medicare covers the service, ((MAA)) the agency will pay the lesser of:
(i) The full coinsurance and deductible amounts due, based upon medicaid's allowed amount; or
(ii) ((MAA's)) The agency's maximum allowable for that service minus the amount paid by medicare.
(b) If medicare does not cover or denies ambulance services that ((MAA)) the agency covers according to this chapter, ((MAA)) the agency pays ((at MAA's)) its maximum allowable fee; except ((MAA)) the agency does not pay for clients on the qualified medicare beneficiaries (QMB) only program.