BILL REQ. #: Z-1187.2
| State of Washington | 61st Legislature | 2010 Regular Session |
Read first time 01/21/10. Referred to Committee on Ways & Means.
AN ACT Relating to administration of the medicaid program; amending RCW 74.09.010, 74.09.015, 74.09.035, 74.09.037, 74.09.050, 74.09.055, 74.09.075, 74.09.080, 74.09.085, 74.09.110, 74.09.120, 74.09.160, 74.09.180, 74.09.185, 74.09.190, 74.09.200, 74.09.210, 74.09.240, 74.09.260, 74.09.280, 74.09.290, 74.09.300, 74.09.470, 74.09.480, 74.09.490, 74.09.500, 74.09.510, 74.09.515, 74.09.520, 74.09.521, 74.09.5221, 74.09.5222, 74.09.5227, 74.09.523, 74.09.530, 74.09.540, 74.09.555, 74.09.565, 74.09.575, 74.09.585, 74.09.595, 74.09.650, 74.09.655, 74.09.658, 74.09.659, 74.09.660, 74.09.700, 74.09.710, 74.09.715, 74.09.725, 74.09.730, 74.09.755, 74.09.790, 74.09.800, 74.09.810, and 74.09.820; and reenacting and amending RCW 74.09.053 and 74.09.522.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1 RCW 74.09.010 and 2007 c 3 s 2 are each amended to read as
follows:
As used in this chapter, unless the context clearly indicates
otherwise:
(1) "Agency" means the single state medicaid agency, designated by
the governor and approved by the United States department of health and
human services in the state plan covering medicaid.
(2) "Children's health program" means the health care services
program provided to children under eighteen years of age and in
households with incomes at or below the federal poverty level as
annually defined by the federal department of health and human services
as adjusted for family size, and who are not otherwise eligible for
medical assistance or the limited casualty program for the medically
needy.
(((2))) (3) "Committee" means the children's health services
committee ((created in section 3 of this act)).
(((3))) (4) "County" means the board of county commissioners,
county council, county executive, or tribal jurisdiction, or its
designee. A combination of two or more county authorities or tribal
jurisdictions may enter into joint agreements ((to fulfill the
requirements of RCW 74.09.415 through 74.09.435)).
(((4) "Department" means the department of social and health
services.))
(5) "Department of health" means the Washington state department of
health created pursuant to RCW 43.70.020.
(6) "Internal management" means the administration of medical
assistance, medical care services, the children's health program, and
the limited casualty program.
(7) "Limited casualty program" means the medical care program
provided to medically needy persons as defined under Title XIX of the
federal social security act, and to medically indigent persons who are
without income or resources sufficient to secure necessary medical
services.
(8) "Medical assistance" means the federal aid medical care program
provided to categorically needy persons as defined under Title XIX of
the federal social security act.
(9) "Medical care services" means the limited scope of care
financed by state funds and provided to general assistance recipients,
and recipients of alcohol and drug addiction services provided under
chapter 74.50 RCW.
(10) "Nursing home" means nursing home as defined in RCW 18.51.010.
(11) "Poverty" means the federal poverty level determined annually
by the United States department of health and human services, or
successor agency.
(12) (("Secretary" means the secretary of social and health
services.)) "Full benefit dual eligible beneficiary" means an individual
who, for any month: Has coverage for the month under a medicare
prescription drug plan or medicare advantage plan with part D coverage;
and is determined eligible by the state for full medicaid benefits for
the month under any eligibility category in the state's medicaid plan
or a section 1115 demonstration waiver that provides pharmacy benefits.
(13)
Sec. 2 RCW 74.09.015 and 2007 c 259 s 16 are each amended to read
as follows:
To the extent that sufficient funding is provided specifically for
this purpose, the ((department)) agency, in collaboration with the
health care authority, shall provide all persons receiving services
under this chapter with access to a twenty-four hour, seven day a week
nurse hotline. The health care authority and the ((department of
social and health services)) agency shall determine the most
appropriate way to provide the nurse hotline under RCW 41.05.037 and
this section, which may include use of the 211 system established in
chapter 43.211 RCW.
Sec. 3 RCW 74.09.035 and 1987 c 406 s 12 are each amended to read
as follows:
(1) To the extent of available funds, medical care services may be
provided to recipients of general assistance, and recipients of alcohol
and drug addiction services provided under chapter 74.50 RCW, in
accordance with medical eligibility requirements established by the
((department)) agency.
(2) Determination of the amount, scope, and duration of medical
care services shall be limited to coverage as defined by the
((department)) agency, except that adult dental, and routine foot care
shall not be included unless there is a specific appropriation for
these services.
(3) The ((department)) agency shall establish standards of
assistance and resource and income exemptions, which may include
deductibles and co-insurance provisions. In addition, the
((department)) agency may include a prohibition against the voluntary
assignment of property or cash for the purpose of qualifying for
assistance.
(4) Residents of skilled nursing homes, intermediate care
facilities, and intermediate care facilities for the mentally retarded
who are eligible for medical care services shall be provided medical
services to the same extent as provided to those persons eligible under
the medical assistance program.
(5) Payments made by the ((department)) agency under this program
shall be the limit of expenditures for medical care services solely
from state funds.
(6) Eligibility for medical care services shall commence with the
date of certification for general assistance or the date of eligibility
for alcohol and drug addiction services provided under chapter 74.50
RCW.
Sec. 4 RCW 74.09.037 and 2004 c 115 s 3 are each amended to read
as follows:
Any card issued after December 31, 2005, by the ((department))
agency or a managed health care system to a person receiving services
under this chapter, that must be presented to providers for purposes of
claims processing, may not display an identification number that
includes more than a four-digit portion of the person's complete social
security number.
Sec. 5 RCW 74.09.050 and 2000 c 5 s 15 are each amended to read
as follows:
The ((secretary)) head of the agency shall appoint such
professional personnel and other assistants and employees, including
professional medical screeners, as may be reasonably necessary to carry
out the provisions of this chapter. The medical screeners shall be
supervised by one or more physicians who shall be appointed by the
((secretary)) head of the agency or his or her designee. The
((secretary)) head of the agency shall appoint a medical director who
is licensed under chapter 18.57 or 18.71 RCW.
Sec. 6 RCW 74.09.053 and 2009 c 568 s 6 and 2009 c 479 s 62 are
each reenacted and amended to read as follows:
(1) Beginning in November 2012, the ((department of social and
health services)) agency, in coordination with the health care
authority, shall by November 15th of each year report to the
legislature:
(a) The number of medical assistance recipients who: (i) Upon
enrollment or recertification had reported being employed, and
beginning with the 2008 report, the month and year they reported being
hired; or (ii) upon enrollment or recertification had reported being
the dependent of someone who was employed, and beginning with the 2008
report, the month and year they reported the employed person was hired.
For recipients identified under (a)(i) and (ii) of this subsection, the
((department)) agency shall report the basis for their medical
assistance eligibility, including but not limited to family medical
coverage, transitional medical assistance, children's medical coverage,
aged coverage, or coverage for persons with disabilities; member
months; and the total cost to the state for these recipients, expressed
as general fund-state and general fund-federal dollars. The
information shall be reported by employer size for employers having
more than fifty employees as recipients or with dependents as
recipients. This information shall be provided for the preceding
January and June of that year.
(b) The following aggregated information: (i) The number of
employees who are recipients or with dependents as recipients by
private and governmental employers; (ii) the number of employees who
are recipients or with dependents as recipients by employer size for
employers with fifty or fewer employees, fifty-one to one hundred
employees, one hundred one to one thousand employees, one thousand one
to five thousand employees and more than five thousand employees; and
(iii) the number of employees who are recipients or with dependents as
recipients by industry type.
(2) For each aggregated classification, the report will include the
number of hours worked, the number of ((department of social and health
services)) agency covered lives, and the total cost to the state for
these recipients. This information shall be for each quarter of the
preceding year.
Sec. 7 RCW 74.09.055 and 2006 c 24 s 1 are each amended to read
as follows:
The ((department)) agency is authorized to establish copayment,
deductible, or coinsurance, or other cost-sharing requirements for
recipients of any medical programs defined in RCW 74.09.010, except
that premiums shall not be imposed on children in households at or
below two hundred percent of the federal poverty level.
Sec. 8 RCW 74.09.075 and 1979 c 141 s 337 are each amended to
read as follows:
The ((department)) agency shall provide (a) for evaluation of
employability when a person is applying for public assistance
representing a medical condition as a basis for need, and (b) for
medical reports to be used in the evaluation of total and permanent
disability. It shall further provide for medical consultation and
assistance in determining the need for special diets, housekeeper and
attendant services, and other requirements as found necessary because
of the medical condition under the rules promulgated by the
((secretary)) head of the agency.
Sec. 9 RCW 74.09.080 and 1979 c 141 s 338 are each amended to
read as follows:
In carrying out the administrative responsibility of this chapter,
the ((department)) agency may contract with an individual or a group,
may utilize existing local state public assistance offices, or
establish separate welfare medical care offices on a county or
multicounty unit basis as found necessary.
Sec. 10 RCW 74.09.085 and 2005 c 446 s 3 are each amended to read
as follows:
The ((secretary)) head of the agency shall, in collaboration with
other state agencies that administer state purchased health care
programs, private health care purchasers, health care facilities,
providers, and carriers, use evidence-based medicine principles to
develop common performance measures and implement financial incentives
in contracts with insuring entities, health care facilities, and
providers that:
(1) Reward improvements in health outcomes for individuals with
chronic diseases, increased utilization of appropriate preventive
health services, and reductions in medical errors; and
(2) Increase, through appropriate incentives to insuring entities,
health care facilities, and providers, the adoption and use of
information technology that contributes to improved health outcomes,
better coordination of care, and decreased medical errors.
Sec. 11 RCW 74.09.110 and 1979 c 141 s 339 are each amended to
read as follows:
The ((department)) agency shall employ administrative personnel in
both state and local offices and employ the services of professional
screeners and consultants as found necessary to carry out the proper
administration of the program.
Sec. 12 RCW 74.09.120 and 1998 c 322 s 45 are each amended to
read as follows:
The ((department)) agency shall purchase necessary physician and
dentist services by contract or "fee for service." The ((department))
agency shall purchase nursing home care by contract and payment for the
care shall be in accordance with the provisions of chapter 74.46 RCW
and rules adopted by the ((department)) agency under the authority of
RCW 74.46.800. No payment shall be made to a nursing home which does
not permit inspection by the ((department of social and health
services)) agency of every part of its premises and an examination of
all records, including financial records, methods of administration,
general and special dietary programs, the disbursement of drugs and
methods of supply, and any other records the ((department)) agency
deems relevant to the regulation of nursing home operations,
enforcement of standards for resident care, and payment for nursing
home services.
The ((department)) agency may purchase nursing home care by
contract in veterans' homes operated by the state department of
veterans affairs and payment for the care shall be in accordance with
the provisions of chapter 74.46 RCW and rules adopted by the
((department)) agency under the authority of RCW 74.46.800.
The ((department)) agency may purchase care in institutions for
((the mentally retarded)) persons with intellectual disabilities, also
known as intermediate care facilities for the mentally retarded. The
((department)) agency shall establish rules for reasonable accounting
and reimbursement systems for such care. Institutions for ((the
mentally retarded)) persons with intellectual disabilities include
licensed nursing homes, public institutions, licensed boarding homes
with fifteen beds or less, and hospital facilities certified as
intermediate care facilities for the mentally retarded under the
federal medicaid program to provide health, habilitative, or
rehabilitative services and twenty-four hour supervision for ((mentally
retarded individuals)) persons with intellectual disabilities or
persons with related conditions and includes in the program "active
treatment" as federally defined.
The ((department)) agency may purchase care in institutions for
mental diseases by contract. The ((department)) agency shall establish
rules for reasonable accounting and reimbursement systems for such
care. Institutions for mental diseases are certified under the federal
medicaid program and primarily engaged in providing diagnosis,
treatment, or care to persons with mental diseases, including medical
attention, nursing care, and related services.
The ((department)) agency may purchase all other services provided
under this chapter by contract or at rates established by the
((department)) agency.
Sec. 13 RCW 74.09.160 and 1991 c 103 s 1 are each amended to read
as follows:
Each vendor or group who has a contract and is rendering service to
eligible persons as defined in this chapter shall submit such charges
as agreed upon between the ((department)) agency and the individual or
group no later than twelve months from the date of service. If the
final charges are not presented within the twelve-month period, they
shall not be a charge against the state. Said twelve-month period may
also be extended by regulation, but only if required by applicable
federal law or regulation, and to no more than the extension of time so
required. For services rendered prior to July 28, 1991, final charges
shall not be a charge against the state unless they are presented
within one hundred twenty days from the date of service.
Sec. 14 RCW 74.09.180 and 1997 c 236 s 1 are each amended to read
as follows:
(1) The provisions of this chapter shall not apply to recipients
whose personal injuries are occasioned by negligence or wrong of
another: PROVIDED, HOWEVER, That the ((secretary)) head of the agency
may furnish assistance, under the provisions of this chapter, for the
results of injuries to or illness of a recipient, and the
((department)) agency shall thereby be subrogated to the recipient's
rights against the recovery had from any tort feasor or the tort
feasor's insurer, or both, and shall have a lien thereupon to the
extent of the value of the assistance furnished by the ((department))
agency. To secure reimbursement for assistance provided under this
section, the ((department)) agency may pursue its remedies under RCW
43.20B.060.
(2) The rights and remedies provided to the ((department)) agency
in this section to secure reimbursement for assistance, including the
((department's)) agency's lien and subrogation rights, may be delegated
to a managed health care system by contract entered into pursuant to
RCW 74.09.522. A managed health care system may enforce all rights and
remedies delegated to it by the ((department)) agency to secure and
recover assistance provided under a managed health care system
consistent with its agreement with the ((department)) agency.
Sec. 15 RCW 74.09.185 and 1995 c 34 s 6 are each amended to read
as follows:
To the extent that payment for covered expenses has been made under
medical assistance for health care items or services furnished to an
individual, in any case where a third party has a legal liability to
make payments, the state is considered to have acquired the rights of
the individual to payment by any other party for those health care
items or services. Recovery pursuant to the subrogation rights,
assignment, or enforcement of the lien granted to the ((department))
agency by this section shall not be reduced, prorated, or applied to
only a portion of a judgment, award, or settlement, except as provided
in RCW 43.20B.050 and 43.20B.060. The doctrine of equitable
subrogation shall not apply to defeat, reduce, or prorate recovery by
the ((department)) agency as to its assignment, lien, or subrogation
rights.
Sec. 16 RCW 74.09.190 and 1979 c 141 s 342 are each amended to
read as follows:
Nothing in this chapter shall be construed as empowering the
((secretary)) head of the agency to compel any recipient of public
assistance and a medical indigent person to undergo any physical
examination, surgical operation, or accept any form of medical
treatment contrary to the wishes of said person who relies on or is
treated by prayer or spiritual means in accordance with the creed and
tenets of any well recognized church or religious denomination.
Sec. 17 RCW 74.09.200 and 1979 ex.s. c 152 s 1 are each amended
to read as follows:
The legislature finds and declares it to be in the public interest
and for the protection of the health and welfare of the residents of
the state of Washington that a proper regulatory and inspection program
be instituted in connection with the providing of medical, dental, and
other health services to recipients of public assistance and medically
indigent persons. In order to effectively accomplish such purpose and
to assure that the recipient of such services receives such services as
are paid for by the state of Washington, the acceptance by the
recipient of such services, and by practitioners of reimbursement for
performing such services, shall authorize the ((secretary of the
department of social and health services)) head of the agency or his or
her designee, to inspect and audit all records in connection with the
providing of such services.
Sec. 18 RCW 74.09.210 and 1989 c 175 s 146 are each amended to
read as follows:
(1) No person, firm, corporation, partnership, association, agency,
institution, or other legal entity, but not including an individual
public assistance recipient of health care, shall, on behalf of himself
or others, obtain or attempt to obtain benefits or payments under this
chapter in a greater amount than that to which entitled by means of:
(a) A willful false statement;
(b) By willful misrepresentation, or by concealment of any material
facts; or
(c) By other fraudulent scheme or device, including, but not
limited to:
(i) Billing for services, drugs, supplies, or equipment that were
unfurnished, of lower quality, or a substitution or misrepresentation
of items billed; or
(ii) Repeated billing for purportedly covered items, which were not
in fact so covered.
(2) Any person or entity knowingly violating any of the provisions
of subsection (1) of this section shall be liable for repayment of any
excess benefits or payments received, plus interest at the rate and in
the manner provided in RCW 43.20B.695. Such person or other entity
shall further, in addition to any other penalties provided by law, be
subject to civil penalties. The ((secretary)) head of the agency may
assess civil penalties in an amount not to exceed three times the
amount of such excess benefits or payments: PROVIDED, That these civil
penalties shall not apply to any acts or omissions occurring prior to
September 1, 1979. RCW 43.20A.215 governs notice of a civil fine and
provides the right to an adjudicative proceeding.
(3) A criminal action need not be brought against a person for that
person to be civilly liable under this section.
(4) In all proceedings under this section, service, adjudicative
proceedings, and judicial review of such determinations shall be in
accordance with chapter 34.05 RCW, the Administrative Procedure Act.
(5) Civil penalties shall be deposited in the general fund upon
their receipt.
Sec. 19 RCW 74.09.240 and 1995 c 319 s 1 are each amended to read
as follows:
(1) Any person, including any corporation, that solicits or
receives any remuneration (including any kickback, bribe, or rebate)
directly or indirectly, overtly or covertly, in cash or in kind
(a) in return for referring an individual to a person for the
furnishing or arranging for the furnishing of any item or service for
which payment may be made in whole or in part under this chapter, or
(b) in return for purchasing, leasing, ordering, or arranging for
or recommending purchasing, leasing, or ordering any goods, facility,
service, or item for which payment may be made in whole or in part
under this chapter,
shall be guilty of a class C felony; however, the fine, if imposed,
shall not be in an amount more than twenty-five thousand dollars,
except as authorized by RCW 9A.20.030.
(2) Any person, including any corporation, that offers or pays any
remuneration (including any kickback, bribe, or rebate) directly or
indirectly, overtly or covertly, in cash or in kind to any person to
induce such person
(a) to refer an individual to a person for the furnishing or
arranging for the furnishing of any item or service for which payment
may be made, in whole or in part, under this chapter, or
(b) to purchase, lease, order, or arrange for or recommend
purchasing, leasing, or ordering any goods, facility, service, or item
for which payment may be made in whole or in part under this chapter,
shall be guilty of a class C felony; however, the fine, if imposed,
shall not be in an amount more than twenty-five thousand dollars,
except as authorized by RCW 9A.20.030.
(3)(a) Except as provided in 42 U.S.C. 1395 nn, physicians are
prohibited from self-referring any client eligible under this chapter
for the following designated health services to a facility in which the
physician or an immediate family member has a financial relationship:
(i) Clinical laboratory services;
(ii) Physical therapy services;
(iii) Occupational therapy services;
(iv) Radiology including magnetic resonance imaging, computerized
axial tomography, and ultrasound services;
(v) Durable medical equipment and supplies;
(vi) Parenteral and enteral nutrients equipment and supplies;
(vii) Prosthetics, orthotics, and prosthetic devices;
(viii) Home health services;
(ix) Outpatient prescription drugs;
(x) Inpatient and outpatient hospital services;
(xi) Radiation therapy services and supplies.
(b) For purposes of this subsection, "financial relationship" means
the relationship between a physician and an entity that includes
either:
(i) An ownership or investment interest; or
(ii) A compensation arrangement.
For purposes of this subsection, "compensation arrangement" means
an arrangement involving remuneration between a physician, or an
immediate family member of a physician, and an entity.
(c) The ((department)) agency is authorized to adopt by rule
amendments to 42 U.S.C. 1395 nn enacted after July 23, 1995.
(d) This section shall not apply in any case covered by a general
exception specified in 42 U.S.C. Sec. 1395 nn.
(4) Subsections (1) and (2) of this section shall not apply to
(a) a discount or other reduction in price obtained by a provider
of services or other entity under this chapter if the reduction in
price is properly disclosed and appropriately reflected in the costs
claimed or charges made by the provider or entity under this chapter,
and
(b) any amount paid by an employer to an employee (who has a bona
fide employment relationship with such employer) for employment in the
provision of covered items or services.
(5) Subsections (1) and (2) of this section, if applicable to the
conduct involved, shall supersede the criminal provisions of chapter
19.68 RCW, but shall not preclude administrative proceedings authorized
by chapter 19.68 RCW.
Sec. 20 RCW 74.09.260 and 1991 sp.s. c 8 s 7 are each amended to
read as follows:
Any person, including any corporation, that knowingly:
(1) Charges, for any service provided to a patient under any
medical care plan authorized under this chapter, money or other
consideration at a rate in excess of the rates established by the
((department of social and health services)) agency; or
(2) Charges, solicits, accepts, or receives, in addition to any
amount otherwise required to be paid under such plan, any gift, money,
donation, or other consideration (other than a charitable, religious,
or philanthropic contribution from an organization or from a person
unrelated to the patient):
(a) As a precondition of admitting a patient to a hospital or
nursing facility; or
(b) As a requirement for the patient's continued stay in such
facility,
when the cost of the services provided therein to the patient is paid
for, in whole or in part, under such plan, shall be guilty of a class
C felony: PROVIDED, That the fine, if imposed, shall not be in an
amount more than twenty-five thousand dollars, except as authorized by
RCW 9A.20.030.
Sec. 21 RCW 74.09.280 and 1979 ex.s. c 152 s 9 are each amended
to read as follows:
The ((secretary of social and health services)) head of the agency
may by rule require that any application, statement, or form filled out
by suppliers of medical care under this chapter shall contain or be
verified by a written statement that it is made under the penalties of
perjury and such declaration shall be in lieu of any oath otherwise
required, and each such paper shall in such event so state. The making
or subscribing of any such papers or forms containing any false or
misleading information may be prosecuted and punished under chapter
9A.72 RCW.
Sec. 22 RCW 74.09.290 and 1994 sp.s. c 9 s 749 are each amended
to read as follows:
The ((secretary of the department of social and health services))
head of the agency or ((his)) the head of the agency's authorized
representative shall have the authority to:
(1) Conduct audits and investigations of providers of medical and
other services furnished pursuant to this chapter, except that the
Washington state medical quality assurance commission shall generally
serve in an advisory capacity to the ((secretary)) head of the agency
in the conduct of audits or investigations of physicians. Any
overpayment discovered as a result of an audit of a provider under this
authority shall be offset by any underpayments discovered in that same
audit sample. In order to determine the provider's actual, usual,
customary, or prevailing charges, the ((secretary)) head of the agency
may examine such random representative records as necessary to show
accounts billed and accounts received except that in the conduct of
such examinations, patient names, other than public assistance
applicants or recipients, shall not be noted, copied, or otherwise made
available to the ((department)) agency. In order to verify costs
incurred by the ((department)) agency for treatment of public
assistance applicants or recipients, the ((secretary)) head of the
agency may examine patient records or portions thereof in connection
with services to such applicants or recipients rendered by a health
care provider, notwithstanding the provisions of RCW 5.60.060,
18.53.200, 18.83.110, or any other statute which may make or purport to
make such records privileged or confidential: PROVIDED, That no
original patient records shall be removed from the premises of the
health care provider, and that the disclosure of any records or
information by the ((department of social and health services)) agency
is prohibited and shall be punishable as a class C felony according to
chapter 9A.20 RCW, unless such disclosure is directly connected to the
official purpose for which the records or information were obtained:
PROVIDED FURTHER, That the disclosure of patient information as
required under this section shall not subject any physician or other
health services provider to any liability for breach of any
confidential relationship between the provider and the patient, but no
evidence resulting from such disclosure may be used in any civil,
administrative, or criminal proceeding against the patient unless a
waiver of the applicable evidentiary privilege is obtained: PROVIDED
FURTHER, That the ((secretary)) head of the agency shall destroy all
copies of patient medical records in their possession upon completion
of the audit, investigation or proceedings;
(2) Approve or deny applications to participate as a provider of
services furnished pursuant to this chapter;
(3) Terminate or suspend eligibility to participate as a provider
of services furnished pursuant to this chapter; and
(4) Adopt, promulgate, amend, and repeal administrative rules, in
accordance with the Administrative Procedure Act, chapter 34.05 RCW, to
carry out the policies and purposes of RCW 74.09.200 through 74.09.290.
Sec. 23 RCW 74.09.300 and 1979 ex.s. c 152 s 11 are each amended
to read as follows:
Whenever the ((secretary of the department of social and health
services)) head of the agency imposes a civil penalty under RCW
74.09.210, or terminates or suspends a provider's eligibility under RCW
74.09.290, he shall, if the provider is licensed pursuant to Titles 18,
70, or 71 RCW, give written notice of such imposition, termination, or
suspension to the appropriate licensing agency or disciplinary board.
Sec. 24 RCW 74.09.470 and 2009 c 463 s 2 are each amended to read
as follows:
(1) Consistent with the goals established in RCW 74.09.402, through
the apple health for kids program authorized in this section, the
((department)) agency shall provide affordable health care coverage to
children under the age of nineteen who reside in Washington state and
whose family income at the time of enrollment is not greater than two
hundred fifty percent of the federal poverty level as adjusted for
family size and determined annually by the federal department of health
and human services, and effective January 1, 2009, and only to the
extent that funds are specifically appropriated therefor, to children
whose family income is not greater than three hundred percent of the
federal poverty level. In administering the program, the
((department)) agency shall take such actions as may be necessary to
ensure the receipt of federal financial participation under the medical
assistance program, as codified at Title XIX of the federal social
security act, the state children's health insurance program, as
codified at Title XXI of the federal social security act, and any other
federal funding sources that are now available or may become available
in the future. The ((department)) agency and the caseload forecast
council shall estimate the anticipated caseload and costs of the
program established in this section.
(2) The ((department)) agency shall accept applications for
enrollment for children's health care coverage; establish appropriate
minimum-enrollment periods, as may be necessary; and determine
eligibility based on current family income. The ((department)) agency
shall make eligibility determinations within the time frames for
establishing eligibility for children on medical assistance, as defined
by RCW 74.09.510. The application and annual renewal processes shall
be designed to minimize administrative barriers for applicants and
enrolled clients, and to minimize gaps in eligibility for families who
are eligible for coverage. If a change in family income results in a
change in the source of funding for coverage, the ((department)) agency
shall transfer the family members to the appropriate source of funding
and notify the family with respect to any change in premium obligation,
without a break in eligibility. The ((department)) agency shall use
the same eligibility redetermination and appeals procedures as those
provided for children on medical assistance programs. The
((department)) agency shall modify its eligibility renewal procedures
to lower the percentage of children failing to annually renew. The
((department)) agency shall manage its outreach, application, and
renewal procedures with the goals of: (a) Achieving year by year
improvements in enrollment, enrollment rates, renewals, and renewal
rates; (b) maximizing the use of existing program databases to obtain
information related to earned and unearned income for purposes of
eligibility determination and renewals, including, but not limited to,
the basic food program, the child care subsidy program, federal social
security administration programs, and the employment security
department wage database; (c) streamlining renewal processes to rely
primarily upon data matches, online submissions, and telephone
interviews; and (d) implementing any other eligibility determination
and renewal processes to allow the state to receive an enhanced federal
matching rate and additional federal outreach funding available through
the federal children's health insurance program reauthorization act of
2009 by January 2010. The ((department)) agency shall advise the
governor and the legislature regarding the status of these efforts by
September 30, 2009. The information provided should include the status
of the ((department's)) agency's efforts, the anticipated impact of
those efforts on enrollment, and the costs associated with that
enrollment.
(3) To ensure continuity of care and ease of understanding for
families and health care providers, and to maximize the efficiency of
the program, the amount, scope, and duration of health care services
provided to children under this section shall be the same as that
provided to children under medical assistance, as defined in RCW
74.09.520.
(4) The primary mechanism for purchasing health care coverage under
this section shall be through contracts with managed health care
systems as defined in RCW 74.09.522, subject to conditions,
limitations, and appropriations provided in the biennial appropriations
act. However, the ((department)) agency shall make every effort within
available resources to purchase health care coverage for uninsured
children whose families have access to dependent coverage through an
employer-sponsored health plan or another source when it is cost-effective for the state to do so, and the purchase is consistent with
requirements of Title XIX and Title XXI of the federal social security
act. To the extent allowable under federal law, the ((department))
agency shall require families to enroll in available employer-sponsored
coverage, as a condition of participating in the program established
under this section, when it is cost-effective for the state to do so.
Families who enroll in available employer-sponsored coverage under this
section shall be accounted for separately in the annual report required
by RCW 74.09.053.
(5)(a) To reflect appropriate parental responsibility, the
((department)) agency shall develop and implement a schedule of
premiums for children's health care coverage due to the ((department))
agency from families with income greater than two hundred percent of
the federal poverty level. For families with income greater than two
hundred fifty percent of the federal poverty level, the premiums shall
be established in consultation with the senate majority and minority
leaders and the speaker and minority leader of the house of
representatives. Premiums shall be set at a reasonable level that does
not pose a barrier to enrollment. The amount of the premium shall be
based upon family income and shall not exceed the premium limitations
in Title XXI of the federal social security act. Premiums shall not be
imposed on children in households at or below two hundred percent of
the federal poverty level as articulated in RCW 74.09.055.
(b) Beginning no later than January 1, 2010, the ((department))
agency shall offer families whose income is greater than three hundred
percent of the federal poverty level the opportunity to purchase health
care coverage for their children through the programs administered
under this section without an explicit premium subsidy from the state.
The design of the health benefit package offered to these children
should provide a benefit package substantially similar to that offered
in the apple health for kids program, and may differ with respect to
cost-sharing, and other appropriate elements from that provided to
children under subsection (3) of this section including, but not
limited to, application of preexisting conditions, waiting periods, and
other design changes needed to offer affordable coverage. The amount
paid by the family shall be in an amount equal to the rate paid by the
state to the managed health care system for coverage of the child,
including any associated and administrative costs to the state of
providing coverage for the child. Any pooling of the program enrollees
that results in state fiscal impact must be identified and brought to
the legislature for consideration.
(6) The ((department)) agency shall undertake and continue a
proactive, targeted outreach and education effort with the goal of
enrolling children in health coverage and improving the health literacy
of youth and parents. The ((department)) agency shall collaborate with
the department of health, local public health jurisdictions, the office
of the superintendent of public instruction, the department of early
learning, health educators, health care providers, health carriers,
community-based organizations, and parents in the design and
development of this effort. The outreach and education effort shall
include the following components:
(a) Broad dissemination of information about the availability of
coverage, including media campaigns;
(b) Assistance with completing applications, and community-based
outreach efforts to help people apply for coverage. Community-based
outreach efforts should be targeted to the populations least likely to
be covered;
(c) Use of existing systems, such as enrollment information from
the free and reduced-price lunch program, the department of early
learning child care subsidy program, the department of health's women,
infants, and children program, and the early childhood education and
assistance program, to identify children who may be eligible but not
enrolled in coverage;
(d) Contracting with community-based organizations and government
entities to support community-based outreach efforts to help families
apply for coverage. These efforts should be targeted to the
populations least likely to be covered. The ((department)) agency
shall provide informational materials for use by government entities
and community-based organizations in their outreach activities, and
should identify any available federal matching funds to support these
efforts;
(e) Development and dissemination of materials to engage and inform
parents and families statewide on issues such as: The benefits of
health insurance coverage; the appropriate use of health services,
including primary care provided by health care practitioners licensed
under chapters 18.71, 18.57, 18.36A, and 18.79 RCW, and emergency
services; the value of a medical home, well-child services and
immunization, and other preventive health services with linkages to
department of health child profile efforts; identifying and managing
chronic conditions such as asthma and diabetes; and the value of good
nutrition and physical activity;
(f) An evaluation of the outreach and education efforts, based upon
clear, cost-effective outcome measures that are included in contracts
with entities that undertake components of the outreach and education
effort;
(g) An implementation plan to develop online application capability
that is integrated with the ((department's)) agency's automated client
eligibility system, and to develop data linkages with the office of the
superintendent of public instruction for free and reduced-price lunch
enrollment information and the department of early learning for child
care subsidy program enrollment information.
(7) The ((department)) agency shall take action to increase the
number of primary care physicians providing dental disease preventive
services including oral health screenings, risk assessment, family
education, the application of fluoride varnish, and referral to a
dentist as needed.
(8) The ((department)) agency shall monitor the rates of
substitution between private-sector health care coverage and the
coverage provided under this section and shall report to appropriate
committees of the legislature by December 2010.
Sec. 25 RCW 74.09.480 and 2009 c 463 s 4 are each amended to read
as follows:
(1) The ((department)) agency, in collaboration with the department
of health, health carriers, local public health jurisdictions,
children's health care providers including pediatricians, family
practitioners, and pediatric subspecialists, community and migrant
health centers, parents, and other purchasers, shall establish a
concise set of explicit performance measures that can indicate whether
children enrolled in the program are receiving health care through an
established and effective medical home, and whether the overall health
of enrolled children is improving. Such indicators may include, but
are not limited to:
(a) Childhood immunization rates;
(b) Well child care utilization rates, including the use of
behavioral and oral health screening, and validated, structured
developmental screens using tools, that are consistent with nationally
accepted pediatric guidelines and recommended administration schedule,
once funding is specifically appropriated for this purpose;
(c) Care management for children with chronic illnesses;
(d) Emergency room utilization;
(e) Visual acuity and eye health;
(f) Preventive oral health service utilization; and
(g) Children's mental health status. In defining these measures
the ((department)) agency shall be guided by the measures provided in
RCW 71.36.025.
Performance measures and targets for each performance measure must
be established and monitored each biennium, with a goal of achieving
measurable, improved health outcomes for the children of Washington
state each biennium.
(2) Beginning in calendar year 2009, targeted provider rate
increases shall be linked to quality improvement measures established
under this section. The ((department)) agency, in conjunction with
those groups identified in subsection (1) of this section, shall
develop parameters for determining criteria for increased payment,
alternative payment methodologies, or other incentives for those
practices and health plans that incorporate evidence-based practice and
improve and achieve sustained improvement with respect to the measures.
(3) The ((department)) agency shall provide a report to the
governor and the legislature related to provider performance on these
measures, beginning in September 2010 for 2007 through 2009 and
biennially thereafter. The ((department)) agency shall advise the
legislature as to its progress towards developing this biennial
reporting system by September 30, 2009.
Sec. 26 RCW 74.09.490 and 2007 c 359 s 5 are each amended to read
as follows:
(1)(a) The ((department)) agency, in consultation with the
evidence-based practice institute established in RCW 71.24.061, shall
develop and implement policies to improve prescribing practices for
treatment of emotional or behavioral disturbances in children, improve
the quality of children's mental health therapy through increased use
of evidence-based and research-based practices and reduced variation in
practice, improve communication and care coordination between primary
care and mental health providers, and prioritize care in the family
home or care which integrates the family where out-of-home placement is
required.
(b) The ((department)) agency shall identify those children with
emotional or behavioral disturbances who may be at high risk due to
off-label use of prescription medication, use of multiple medications,
high medication dosage, or lack of coordination among multiple
prescribing providers, and establish one or more mechanisms to evaluate
the appropriateness of the medication these children are using,
including but not limited to obtaining second opinions from experts in
child psychiatry.
(c) The ((department)) agency shall review the psychotropic
medications of all children under five and establish one or more
mechanisms to evaluate the appropriateness of the medication these
children are using, including but not limited to obtaining second
opinions from experts in child psychiatry.
(d) The ((department)) agency shall track prescriptive practices
with respect to psychotropic medications with the goal of reducing the
use of medication.
(e) The ((department)) agency shall encourage the use of cognitive
behavioral therapies and other treatments which are empirically
supported or evidence-based, in addition to or in the place of
prescription medication where appropriate.
(2) The ((department)) agency shall convene a representative group
of regional support networks, community mental health centers, and
managed health care systems contracting with the ((department)) agency
under RCW 74.09.522 to:
(a) Establish mechanisms and develop contract language that ensures
increased coordination of and access to medicaid mental health benefits
available to children and their families, including ensuring access to
services that are identified as a result of a developmental screen
administered through early periodic screening, diagnosis, and
treatment;
(b) Define managed health care system and regional support network
contractual performance standards that track access to and utilization
of services; and
(c) Set standards for reducing the number of children that are
prescribed antipsychotic drugs and receive no outpatient mental health
services with their medication.
(3) The ((department)) agency shall submit a report on progress and
any findings under this section to the legislature by January 1, 2009.
Sec. 27 RCW 74.09.500 and 1979 c 141 s 343 are each amended to
read as follows:
There is hereby established a new program of federal-aid assistance
to be known as medical assistance to be administered by the ((state
department of social and health services)) agency. The ((department of
social and health services)) agency is authorized to comply with the
federal requirements for the medical assistance program provided in the
Social Security Act and particularly Title XIX of Public Law (89-97) in
order to secure federal matching funds for such program.
Sec. 28 RCW 74.09.510 and 2007 c 315 s 1 are each amended to read
as follows:
Medical assistance may be provided in accordance with eligibility
requirements established by the ((department)) agency, as defined in
the social security Title XIX state plan for mandatory categorically
needy persons and:
(1) Individuals who would be eligible for cash assistance except
for their institutional status;
(2) Individuals who are under twenty-one years of age, who would be
eligible for medicaid, but do not qualify as dependent children and who
are in (a) foster care, (b) subsidized adoption, (c) a nursing facility
or an intermediate care facility for persons who are mentally retarded,
or (d) inpatient psychiatric facilities;
(3) Individuals who:
(a) Are under twenty-one years of age;
(b) On or after July 22, 2007, were in foster care under the legal
responsibility of the department of social and health services or a
federally recognized tribe located within the state; and
(c) On their eighteenth birthday, were in foster care under the
legal responsibility of the department of social and health services or
a federally recognized tribe located within the state;
(4) Persons who are aged, blind, or disabled who: (a) Receive only
a state supplement, or (b) would not be eligible for cash assistance if
they were not institutionalized;
(5) Categorically eligible individuals who meet the income and
resource requirements of the cash assistance programs;
(6) Individuals who are enrolled in managed health care systems,
who have otherwise lost eligibility for medical assistance, but who
have not completed a current six-month enrollment in a managed health
care system, and who are eligible for federal financial participation
under Title XIX of the social security act;
(7) Children and pregnant women allowed by federal statute for whom
funding is appropriated;
(8) Working individuals with disabilities authorized under section
1902(a)(10)(A)(ii) of the social security act for whom funding is
appropriated;
(9) Other individuals eligible for medical services under RCW
74.09.035 and 74.09.700 for whom federal financial participation is
available under Title XIX of the social security act;
(10) Persons allowed by section 1931 of the social security act for
whom funding is appropriated; and
(11) Women who: (a) Are under sixty-five years of age; (b) have
been screened for breast and cervical cancer under the national breast
and cervical cancer early detection program administered by the
department of health or tribal entity and have been identified as
needing treatment for breast or cervical cancer; and (c) are not
otherwise covered by health insurance. Medical assistance provided
under this subsection is limited to the period during which the woman
requires treatment for breast or cervical cancer, and is subject to any
conditions or limitations specified in the omnibus appropriations act.
Sec. 29 RCW 74.09.515 and 2007 c 359 s 8 are each amended to read
as follows:
(1) The department of social and health services shall adopt rules
and policies providing that when youth who were enrolled in a medical
assistance program immediately prior to confinement are released from
confinement, their medical assistance coverage will be fully reinstated
on the day of their release, subject to any expedited review of their
continued eligibility for medical assistance coverage that is required
under federal or state law.
(2) The department of social and health services, in collaboration
with county juvenile court administrators and regional support
networks, shall establish procedures for coordination between
department of social and health services field offices, juvenile
rehabilitation administration institutions, and county juvenile courts
that result in prompt reinstatement of eligibility and speedy
eligibility determinations for youth who are likely to be eligible for
medical assistance services upon release from confinement. Procedures
developed under this subsection must address:
(a) Mechanisms for receiving medical assistance services'
applications on behalf of confined youth in anticipation of their
release from confinement;
(b) Expeditious review of applications filed by or on behalf of
confined youth and, to the extent practicable, completion of the review
before the youth is released; and
(c) Mechanisms for providing medical assistance services' identity
cards to youth eligible for medical assistance services immediately
upon their release from confinement.
(3) For purposes of this section, "confined" or "confinement" means
detained in a facility operated by or under contract with the
department of social and health services, juvenile rehabilitation
administration, or detained in a juvenile detention facility operated
under chapter 13.04 RCW.
(4) The department of social and health services shall adopt
standardized statewide screening and application practices and forms
designed to facilitate the application of a confined youth who is
likely to be eligible for a medical assistance program.
Sec. 30 RCW 74.09.520 and 2007 c 3 s 1 are each amended to read
as follows:
(1) The term "medical assistance" may include the following care
and services: (a) Inpatient hospital services; (b) outpatient hospital
services; (c) other laboratory and X-ray services; (d) nursing facility
services; (e) physicians' services, which shall include prescribed
medication and instruction on birth control devices; (f) medical care,
or any other type of remedial care as may be established by the
((secretary)) agency; (g) home health care services; (h) private duty
nursing services; (i) dental services; (j) physical and occupational
therapy and related services; (k) prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician skilled in
diseases of the eye or by an optometrist, whichever the individual may
select; (l) personal care services, as provided in this section; (m)
hospice services; (n) other diagnostic, screening, preventive, and
rehabilitative services; and (o) like services when furnished to a
child by a school district in a manner consistent with the requirements
of this chapter. For the purposes of this section, the ((department))
agency may not cut off any prescription medications, oxygen supplies,
respiratory services, or other life-sustaining medical services or
supplies.
"Medical assistance," notwithstanding any other provision of law,
shall not include routine foot care, or dental services delivered by
any health care provider, that are not mandated by Title XIX of the
social security act unless there is a specific appropriation for these
services.
(2) The ((department)) agency shall amend the state plan for
medical assistance under Title XIX of the federal social security act
to include personal care services, as defined in 42 C.F.R. 440.170(f),
in the categorically needy program.
(3) The ((department)) agency shall adopt, amend, or rescind such
administrative rules as are necessary to ensure that Title XIX personal
care services are provided to eligible persons in conformance with
federal regulations.
(a) These administrative rules shall include financial eligibility
indexed according to the requirements of the social security act
providing for medicaid eligibility.
(b) The rules shall require clients be assessed as having a medical
condition requiring assistance with personal care tasks. Plans of care
for clients requiring health-related consultation for assessment and
service planning may be reviewed by a nurse.
(c) The ((department)) agency shall determine by rule which clients
have a health-related assessment or service planning need requiring
registered nurse consultation or review. This definition may include
clients that meet indicators or protocols for review, consultation, or
visit.
(4) The ((department)) agency shall design and implement a means to
assess the level of functional disability of persons eligible for
personal care services under this section. The personal care services
benefit shall be provided to the extent funding is available according
to the assessed level of functional disability. Any reductions in
services made necessary for funding reasons should be accomplished in
a manner that assures that priority for maintaining services is given
to persons with the greatest need as determined by the assessment of
functional disability.
(5) Effective July 1, 1989, the ((department)) agency shall offer
hospice services in accordance with available funds.
(6) For Title XIX personal care services administered by ((aging
and disability services administration of the department)) the agency,
the ((department)) agency shall contract with area agencies on aging:
(a) To provide case management services to individuals receiving
Title XIX personal care services in their own home; and
(b) To reassess and reauthorize Title XIX personal care services or
other home and community services as defined in RCW 74.39A.009 in home
or in other settings for individuals consistent with the intent of this
section:
(i) Who have been initially authorized by the ((department)) agency
to receive Title XIX personal care services or other home and community
services as defined in RCW 74.39A.009; and
(ii) Who, at the time of reassessment and reauthorization, are
receiving such services in their own home.
(7) In the event that an area agency on aging is unwilling to enter
into or satisfactorily fulfill a contract or an individual consumer's
need for case management services will be met through an alternative
delivery system, the ((department)) agency is authorized to:
(a) Obtain the services through competitive bid; and
(b) Provide the services directly until a qualified contractor can
be found.
(8) Subject to the availability of amounts appropriated for this
specific purpose, effective July 1, 2007, the ((department)) agency may
offer medicare part D prescription drug copayment coverage to full
benefit dual eligible beneficiaries.
Sec. 31 RCW 74.09.521 and 2009 c 388 s 1 are each amended to read
as follows:
(1) To the extent that funds are specifically appropriated for this
purpose the ((department)) agency shall revise its medicaid healthy
options managed care and fee-for-service program standards under
medicaid, Title XIX of the federal social security act to improve
access to mental health services for children who do not meet the
regional support network access to care standards. Effective July 1,
2008, the program standards shall be revised to allow outpatient
therapy services to be provided by licensed mental health
professionals, as defined in RCW 71.34.020, or by a mental health
professional regulated under Title 18 RCW who is under the direct
supervision of a licensed mental health professional, and up to twenty
outpatient therapy hours per calendar year, including family therapy
visits integral to a child's treatment. This section shall be
administered in a manner consistent with federal early periodic
screening, diagnosis, and treatment requirements related to the receipt
of medically necessary services when a child's need for such services
is identified through developmental screening.
(2) The ((department)) agency and the children's mental health
evidence-based practice institute established in RCW 71.24.061 shall
collaborate to encourage and develop incentives for the use of
prescribing practices and evidence-based and research-based treatment
practices developed under RCW 74.09.490 by mental health professionals
serving children under this section.
Sec. 32 RCW 74.09.522 and 1997 c 59 s 15 and 1997 c 34 s 1 are
each reenacted and amended to read as follows:
(1) For the purposes of this section, "managed health care system"
means any health care organization, including health care providers,
insurers, health care service contractors, health maintenance
organizations, health insuring organizations, or any combination
thereof, that provides directly or by contract health care services
covered under RCW 74.09.520 and rendered by licensed providers, on a
prepaid capitated basis and that meets the requirements of section
1903(m)(1)(A) of Title XIX of the federal social security act or
federal demonstration waivers granted under section 1115(a) of Title XI
of the federal social security act.
(2) The ((department of social and health services)) agency shall
enter into agreements with managed health care systems to provide
health care services to recipients of temporary assistance for needy
families under the following conditions:
(a) Agreements shall be made for at least thirty thousand
recipients statewide;
(b) Agreements in at least one county shall include enrollment of
all recipients of temporary assistance for needy families;
(c) To the extent that this provision is consistent with section
1903(m) of Title XIX of the federal social security act or federal
demonstration waivers granted under section 1115(a) of Title XI of the
federal social security act, recipients shall have a choice of systems
in which to enroll and shall have the right to terminate their
enrollment in a system: PROVIDED, That the ((department)) agency may
limit recipient termination of enrollment without cause to the first
month of a period of enrollment, which period shall not exceed twelve
months: AND PROVIDED FURTHER, That the ((department)) agency shall not
restrict a recipient's right to terminate enrollment in a system for
good cause as established by the ((department)) agency by rule;
(d) To the extent that this provision is consistent with section
1903(m) of Title XIX of the federal social security act, participating
managed health care systems shall not enroll a disproportionate number
of medical assistance recipients within the total numbers of persons
served by the managed health care systems, except as authorized by the
((department)) agency under federal demonstration waivers granted under
section 1115(a) of Title XI of the federal social security act;
(e) In negotiating with managed health care systems the
((department)) agency shall adopt a uniform procedure to negotiate and
enter into contractual arrangements, including standards regarding the
quality of services to be provided; and financial integrity of the
responding system;
(f) The ((department)) agency shall seek waivers from federal
requirements as necessary to implement this chapter;
(g) The ((department)) agency shall, wherever possible, enter into
prepaid capitation contracts that include inpatient care. However, if
this is not possible or feasible, the ((department)) agency may enter
into prepaid capitation contracts that do not include inpatient care;
(h) The ((department)) agency shall define those circumstances
under which a managed health care system is responsible for out-of-plan
services and assure that recipients shall not be charged for such
services; and
(i) Nothing in this section prevents the ((department)) agency from
entering into similar agreements for other groups of people eligible to
receive services under this chapter.
(3) The ((department)) agency shall ensure that publicly supported
community health centers and providers in rural areas, who show serious
intent and apparent capability to participate as managed health care
systems are seriously considered as contractors. The ((department))
agency shall coordinate its managed care activities with activities
under chapter 70.47 RCW.
(4) The ((department)) agency shall work jointly with the state of
Oregon and other states in this geographical region in order to develop
recommendations to be presented to the appropriate federal agencies and
the United States congress for improving health care of the poor, while
controlling related costs.
(5) The legislature finds that competition in the managed health
care marketplace is enhanced, in the long term, by the existence of a
large number of managed health care system options for medicaid
clients. In a managed care delivery system, whose goal is to focus on
prevention, primary care, and improved enrollee health status,
continuity in care relationships is of substantial importance, and
disruption to clients and health care providers should be minimized.
To help ensure these goals are met, the following principles shall
guide the ((department)) agency in its healthy options managed health
care purchasing efforts:
(a) All managed health care systems should have an opportunity to
contract with the ((department)) agency to the extent that minimum
contracting requirements defined by the ((department)) agency are met,
at payment rates that enable the ((department)) agency to operate as
far below appropriated spending levels as possible, consistent with the
principles established in this section.
(b) Managed health care systems should compete for the award of
contracts and assignment of medicaid beneficiaries who do not
voluntarily select a contracting system, based upon:
(i) Demonstrated commitment to or experience in serving low-income
populations;
(ii) Quality of services provided to enrollees;
(iii) Accessibility, including appropriate utilization, of services
offered to enrollees;
(iv) Demonstrated capability to perform contracted services,
including ability to supply an adequate provider network;
(v) Payment rates; and
(vi) The ability to meet other specifically defined contract
requirements established by the ((department)) agency, including
consideration of past and current performance and participation in
other state or federal health programs as a contractor.
(c) Consideration should be given to using multiple year
contracting periods.
(d) Quality, accessibility, and demonstrated commitment to serving
low-income populations shall be given significant weight in the
contracting, evaluation, and assignment process.
(e) All contractors that are regulated health carriers must meet
state minimum net worth requirements as defined in applicable state
laws. The ((department)) agency shall adopt rules establishing the
minimum net worth requirements for contractors that are not regulated
health carriers. This subsection does not limit the authority of the
((department)) agency to take action under a contract upon finding that
a contractor's financial status seriously jeopardizes the contractor's
ability to meet its contract obligations.
(f) Procedures for resolution of disputes between the
((department)) agency and contract bidders or the ((department)) agency
and contracting carriers related to the award of, or failure to award,
a managed care contract must be clearly set out in the procurement
document. In designing such procedures, the ((department)) agency
shall give strong consideration to the negotiation and dispute
resolution processes used by the Washington state health care authority
in its managed health care contracting activities.
(6) The ((department)) agency may apply the principles set forth in
subsection (5) of this section to its managed health care purchasing
efforts on behalf of clients receiving supplemental security income
benefits to the extent appropriate.
Sec. 33 RCW 74.09.5221 and 1997 c 231 s 112 are each amended to
read as follows:
To the extent that federal statutes or regulations, or provisions
of waivers granted to the ((department of social and health services))
agency by the federal department of health and human services, include
standards that differ from the minimums stated in sections 101 through
106, 109, and 111 of this act, those sections do not apply to contracts
with health carriers awarded pursuant to RCW 74.09.522.
Sec. 34 RCW 74.09.5222 and 2009 c 545 s 4 are each amended to
read as follows:
(1) The ((department)) agency shall submit a section 1115
demonstration waiver request to the federal department of health and
human services to expand and revise the medical assistance program as
codified in Title XIX of the federal social security act. The waiver
request should be designed to ensure the broadest federal financial
participation under Title XIX and XXI of the federal social security
act. To the extent permitted under federal law, the waiver request
should include the following components:
(a) Establishment of a single eligibility standard for low-income
persons, including expansion of categorical eligibility to include
childless adults. The ((department)) agency shall request that the
single eligibility standard be phased in such that incremental steps
are taken to cover additional low-income parents and individuals over
time, with the goal of offering coverage to persons with household
income at or below two hundred percent of the federal poverty level;
(b) Establishment of a single seamless application and eligibility
determination system for all state low-income medical programs included
in the waiver. Applications may be electronic and may include an
electronic signature for verification and authentication. Eligibility
determinations should maximize federal financing where possible;
(c) The delivery of all low-income coverage programs as a single
program, with a common core benefit package that may be similar to the
basic health benefit package or an alternative benefit package approved
by the secretary of the federal department of health and human
services, including the option of supplemental coverage for select
categorical groups, such as children, and individuals who are aged,
blind, and disabled;
(d) A program design to include creative and innovative approaches
such as: Coverage for preventive services with incentives to use
appropriate preventive care; enhanced medical home reimbursement and
bundled payment methodologies; cost-sharing options; use of care
management and care coordination programs to improve coordination of
medical and behavioral health services; application of an innovative
predictive risk model to better target care management services; and
mandatory enrollment in managed care, as may be necessary;
(e) The ability to impose enrollment limits or benefit design
changes for eligibility groups that were not eligible under the Title
XIX state plan in effect on the date of submission of the waiver
application;
(f) A premium assistance program whereby employers can participate
in coverage options for employees and dependents of employees otherwise
eligible under the waiver. The waiver should make every effort to
maximize enrollment in employer-sponsored health insurance when it is
cost-effective for the state to do so, and the purchase is consistent
with the requirements of Titles XIX and XXI of the federal social
security act. To the extent allowable under federal law, the
((department)) agency shall require enrollment in available employer-sponsored coverage as a condition of eligibility for coverage under the
waiver; and
(g) The ability to share savings that might accrue to the federal
medicare program, Title XVIII of the federal social security act, from
improved care management for persons who are eligible for both medicare
and medicaid. Through the waiver application process, the
((department)) agency shall determine whether the state could serve,
directly or by contract, as a medicare special needs plan for persons
eligible for both medicare and medicaid.
(2) The ((department)) agency shall hold ongoing stakeholder
discussions as it is developing the waiver request, and provide
opportunities for public review and comment as the request is being
developed.
(3) The ((department)) agency and the health care authority shall
identify statutory changes that may be necessary to ensure successful
and timely implementation of the waiver request as submitted to the
federal department of health and human services as the apple health
program for adults.
(4) The legislature must authorize implementation of any waiver
approved by the federal department of health and human services under
this section.
Sec. 35 RCW 74.09.5227 and 2001 2nd sp.s. c 2 s 3 are each
amended to read as follows:
The ((department)) agency shall implement the program created in
RCW 74.09.5225 within sixty days of September 20, 2001, regardless of
the beneficiary's managed care status.
Sec. 36 RCW 74.09.523 and 2001 c 191 s 2 are each amended to read
as follows:
(1) The definitions in this subsection apply throughout this
section unless the context clearly requires otherwise.
(a) "PACE" means the program of all-inclusive care for the elderly,
a managed care medicare/medicaid program authorized under sections
1894, 1905(a), and 1934 of the social security act and administered by
the ((department)) agency.
(b) "PACE program agreement" means an agreement between a PACE
organization, the health care financing administration, and the
((department)) agency.
(2) A PACE program may operate in the state only in accordance with
a PACE program agreement with the ((department)) agency.
(3) A PACE program shall at the time of entering into the initial
PACE program agreement, and at each renewal thereof, demonstrate cash
reserves to cover expenses in the event of insolvency.
(a) The cash reserves at a minimum shall equal the sum of:
(i) One month's total capitation revenue; and
(ii) One month's average payment to subcontractors.
(b) The program may demonstrate cash reserves to cover expenses of
insolvency with one or more of the following: Reasonable and
sufficient net worth, insolvency insurance, or parental guarantees.
(4) A PACE program must provide full disclosure regarding the terms
of enrollment and the option to disenroll at any time to all persons
who seek to participate or who are participants in the program.
Sec. 37 RCW 74.09.530 and 2007 c 315 s 2 are each amended to read
as follows:
(1) The amount and nature of medical assistance and the
determination of eligibility of recipients for medical assistance shall
be the responsibility of the ((department of social and health
services)) agency. The ((department)) agency shall establish
reasonable standards of assistance and resource and income exemptions
which shall be consistent with the provisions of the Social Security
Act and with the regulations of the secretary of health, education and
welfare for determining eligibility of individuals for medical
assistance and the extent of such assistance to the extent that funds
are available from the state and federal government. The
((department)) agency shall not consider resources in determining
continuing eligibility for recipients eligible under section 1931 of
the social security act.
(2) Individuals eligible for medical assistance under RCW
74.09.510(3) shall be transitioned into coverage under that subsection
immediately upon their termination from coverage under RCW
74.09.510(2)(a). The ((department)) agency shall use income
eligibility standards and eligibility determinations applicable to
children placed in foster care. The ((department)) agency, in
consultation with the health care authority, shall provide information
regarding basic health plan enrollment and shall offer assistance with
the application and enrollment process to individuals covered under RCW
74.09.510(3) who are approaching their twenty-first birthday.
Sec. 38 RCW 74.09.540 and 2001 2nd sp.s. c 15 s 2 are each
amended to read as follows:
(1) It is the intent of the legislature to remove barriers to
employment for individuals with disabilities by providing medical
assistance to ((the)) working ((disabled)) persons with disabilities
through a buy-in program in accordance with section 1902(a)(10)(A)(ii)
of the social security act and eligibility and cost-sharing
requirements established by the ((department)) agency.
(2) The ((department)) agency shall establish income, resource, and
cost-sharing requirements for the buy-in program in accordance with
federal law and any conditions or limitations specified in the omnibus
appropriations act. The ((department)) agency shall establish and
modify eligibility and cost-sharing requirements in order to administer
the program within available funds. The ((department)) agency shall
make every effort to coordinate benefits with employer-sponsored
coverage available to the working disabled receiving benefits under
this chapter.
Sec. 39 RCW 74.09.555 and 2005 c 503 s 12 are each amended to
read as follows:
(1) The ((department)) agency shall adopt rules and policies
providing that when persons with a mental disorder, who were enrolled
in medical assistance immediately prior to confinement, are released
from confinement, their medical assistance coverage will be fully
reinstated on the day of their release, subject to any expedited review
of their continued eligibility for medical assistance coverage that is
required under federal or state law.
(2) The ((department)) agency, in collaboration with the Washington
association of sheriffs and police chiefs, the department of
corrections, and the regional support networks, shall establish
procedures for coordination between ((department)) agency field
offices, institutions for mental disease, and correctional
institutions, as defined in RCW 9.94.049, that result in prompt
reinstatement of eligibility and speedy eligibility determinations for
persons who are likely to be eligible for medical assistance services
upon release from confinement. Procedures developed under this
subsection must address:
(a) Mechanisms for receiving medical assistance services
applications on behalf of confined persons in anticipation of their
release from confinement;
(b) Expeditious review of applications filed by or on behalf of
confined persons and, to the extent practicable, completion of the
review before the person is released;
(c) Mechanisms for providing medical assistance services identity
cards to persons eligible for medical assistance services immediately
upon their release from confinement; and
(d) Coordination with the federal social security administration,
through interagency agreements or otherwise, to expedite processing of
applications for federal supplemental security income or social
security disability benefits, including federal acceptance of
applications on behalf of confined persons.
(3) Where medical or psychiatric examinations during a person's
confinement indicate that the person is disabled, the correctional
institution or institution for mental diseases shall provide the
((department)) agency with that information for purposes of making
medical assistance eligibility and enrollment determinations prior to
the person's release from confinement. The ((department)) agency
shall, to the maximum extent permitted by federal law, use the
examination in making its determination whether the person is disabled
and eligible for medical assistance.
(4) For purposes of this section, "confined" or "confinement" means
incarcerated in a correctional institution, as defined in RCW 9.94.049,
or admitted to an institute for mental disease, as defined in 42 C.F.R.
part 435, Sec. 1009 on July 24, 2005.
(5) For purposes of this section, "likely to be eligible" means
that a person:
(a) Was enrolled in medicaid or supplemental security income or
general assistance immediately before he or she was confined and his or
her enrollment was terminated during his or her confinement; or
(b) Was enrolled in medicaid or supplemental security income or
general assistance at any time during the five years before his or her
confinement, and medical or psychiatric examinations during the
person's confinement indicate that the person continues to be disabled
and the disability is likely to last at least twelve months following
release.
(6) The economic services administration shall adopt standardized
statewide screening and application practices and forms designed to
facilitate the application of a confined person who is likely to be
eligible for medicaid.
Sec. 40 RCW 74.09.565 and 1989 c 87 s 4 are each amended to read
as follows:
(1) An agreement between spouses transferring or assigning rights
to future income from one spouse to the other shall be invalid for
purposes of determining eligibility for medical assistance or the
limited casualty program for the medically needy, but this subsection
does not affect agreements between spouses transferring or assigning
resources, and income produced by transferred or assigned resources
shall continue to be recognized as the separate income of the
transferee.
(2) In determining eligibility for medical assistance or the
limited casualty program for the medically needy for a married person
in need of institutional care, or care under home and community-based
waivers as defined in Title XIX of the social security act, if the
community income received in the name of the nonapplicant spouse
exceeds the community income received in the name of the applicant
spouse, the applicant's interest in that excess shall be considered
unavailable to the applicant.
(3) The ((department)) agency shall adopt rules consistent with the
provisions of section 1924 of the social security act entitled
"Treatment of Income and Resources for Certain Institutionalized
Spouses," in determining the allocation of income between an
institutionalized and community spouse.
(4) The ((department)) agency shall establish the monthly
maintenance needs allowance for the community spouse up to the maximum
amount allowed by state appropriation or within available funds and
permitted in section 1924 of the social security act. The total
monthly needs allowance shall not exceed one thousand five hundred
dollars, subject to adjustment provided in section 1924 of the social
security act.
Sec. 41 RCW 74.09.575 and 2003 1st sp.s. c 28 s 1 are each
amended to read as follows:
(1) The ((department)) agency shall promulgate rules consistent
with the treatment of resources provisions of section 1924 of the
social security act entitled "Treatment of Income and Resources for
Certain Institutionalized Spouses," in determining the allocation of
resources between the institutionalized and community spouse.
(2) In the interest of supporting the community spouse the
((department)) agency shall allow the maximum resource allowance amount
permissible under the social security act for the community spouse for
persons institutionalized before August 1, 2003.
(3) For persons institutionalized on or after August 1, 2003, the
((department)) agency, in the interest of supporting the community
spouse, shall allow up to a maximum of forty thousand dollars in
resources for the community spouse. For the fiscal biennium beginning
July 1, 2005, and each fiscal biennium thereafter, the maximum resource
allowance amount for the community spouse shall be adjusted for
economic trends and conditions by increasing the amount allowable by
the consumer price index as published by the federal bureau of labor
statistics. However, in no case shall the amount allowable exceed the
maximum resource allowance permissible under the social security act.
Sec. 42 RCW 74.09.585 and 1995 1st sp.s. c 18 s 81 are each
amended to read as follows:
(1) The ((department)) agency shall establish standards consistent
with section 1917 of the social security act in determining the period
of ineligibility for medical assistance due to the transfer of
resources.
(2) There shall be no penalty imposed for the transfer of assets
that are excluded in a determination of the individual's eligibility
for medicaid to the extent such assets are protected by the long-term
care insurance policy or contract pursuant to chapter 48.85 RCW.
(3) The ((department)) agency may waive a period of ineligibility
if the ((department)) agency determines that denial of eligibility
would work an undue hardship.
Sec. 43 RCW 74.09.595 and 1989 c 87 s 8 are each amended to read
as follows:
The ((department)) agency shall in compliance with section 1924 of
the social security act adopt procedures which provide due process for
institutionalized or community spouses who request a fair hearing as to
the valuation of resources, the amount of the community spouse resource
allowance, or the monthly maintenance needs allowance.
Sec. 44 RCW 74.09.650 and 2003 1st sp.s. c 29 s 2 are each
amended to read as follows:
(1) To the extent funds are appropriated specifically for this
purpose, and subject to any conditions placed on appropriations made
for this purpose, the ((department)) agency shall design a medicaid
prescription drug assistance program. Neither the benefits of, nor
eligibility for, the program is considered to be an entitlement.
(2) The ((department)) agency shall request any federal waiver
necessary to implement this program. Consistent with federal waiver
conditions, the ((department)) agency may charge enrollment fees,
premiums, or point-of-service cost-sharing to program enrollees.
(3) Eligibility for this program is limited to persons:
(a) Who are eligible for medicare or age sixty-five and older;
(b) Whose family income does not exceed two hundred percent of the
federal poverty level as adjusted for family size and determined
annually by the federal department of health and human services;
(c) Who lack insurance that provides prescription drug coverage;
and
(d) Who are not otherwise eligible under Title XIX of the federal
social security act.
(4) The ((department)) agency shall use a cost-effective
prescription drug benefit design. Consistent with federal waiver
conditions, this benefit design may be different than the benefit
design offered under the medical assistance program. The benefit
design may include a deductible benefit that provides coverage when
enrollees incur higher prescription drug costs as defined by the
((department)) agency. The ((department)) agency also may offer more
than one benefit design.
(5) The ((department)) agency shall limit enrollment of persons who
qualify for the program so as to prevent an overexpenditure of
appropriations for this program or to assure necessary compliance with
federal waiver budget neutrality requirements. The ((department))
agency may not reduce existing medical assistance program eligibility
or benefits to assure compliance with federal waiver budget neutrality
requirements.
(6) Premiums paid by medicaid enrollees not in the medicaid
prescription drug assistance program may not be used to finance the
medicaid prescription drug assistance program.
(7) This program will be terminated within twelve months after
implementation of a prescription drug benefit under Title XVIII of the
federal social security act.
(8) The ((department)) agency shall provide recommendations to the
appropriate committees of the senate and house of representatives by
November 15, 2003, on financing options available to support the
medicaid prescription drug assistance program. In recommending
financing options, the ((department)) agency shall explore every
opportunity to maximize federal funding to support the program.
Sec. 45 RCW 74.09.655 and 2008 c 245 s 1 are each amended to read
as follows:
The ((department)) agency shall provide coverage under this chapter
for smoking cessation counseling services, as well as prescription and
nonprescription agents when used to promote smoking cessation, so long
as such agents otherwise meet the definition of "covered outpatient
drug" in 42 U.S.C. Sec. 1396r-8(k). However, the ((department)) agency
may initiate an individualized inquiry and determine and implement by
rule appropriate coverage limitations as may be required to encourage
the use of effective, evidence-based services and prescription and
nonprescription agents. The ((department)) agency shall track
per-capita expenditures for a cohort of clients that receive smoking
cessation benefits, and submit a cost-benefit analysis to the
legislature on or before January 1, 2012.
Sec. 46 RCW 74.09.658 and 2009 c 326 s 1 are each amended to read
as follows:
(1) The home health program shall require registered nurse
oversight and intervention, as appropriate. In-person contact between
a home health care registered nurse and a patient is not required under
the state's medical assistance program for home health services that
are: (a) Delivered with the assistance of telemedicine and (b)
otherwise eligible for reimbursement as a medically necessary skilled
home health nursing visit under the program.
(2) The ((department)) agency in consultation with home health care
service providers shall develop reimbursement rules and, in rule,
define the requirements that must be met for a reimbursable skilled
nursing visit when services are rendered without a face-to-face visit
and are assisted by telemedicine.
(3)(a) The ((department)) agency shall establish the reimbursement
rate for skilled home health nursing services delivered with the
assistance of telemedicine that meet the requirements of a reimbursable
visit as defined by the ((department)) agency.
(b) Reimbursement is not provided for purchase or lease of
telemedicine equipment.
(4) Any home health agency licensed under chapter 70.127 RCW and
eligible for reimbursement under the medical programs authorized under
this chapter may be reimbursed for services under this section if the
service meets the requirements for a reimbursable skilled nursing visit
as defined by the ((department)) agency.
(5) Nothing in this section shall be construed to alter the scope
of practice of any home health care services provider or authorizes the
delivery of home health care services in a setting or manner not
otherwise authorized by law.
(6) The use of telemedicine is not intended to replace registered
nurse health care ((visit[s])) visits when necessary.
(7) For the purposes of this section, "telemedicine" means the use
of telemonitoring to enhance the delivery of certain home health
medical services through:
(a) The provision of certain education related to health care
services using audio, video, or data communication instead of a face-to-face visit; or
(b) The collection of clinical data and the transmission of such
data between a patient at a distant location and the home health
provider through electronic processing technologies. Objective
clinical data that may be transmitted includes, but is not limited to,
weight, blood pressure, pulse, respirations, blood glucose, and pulse
oximetry.
Sec. 47 RCW 74.09.659 and 2009 c 545 s 5 are each amended to read
as follows:
(1) The ((department)) agency shall continue to submit applications
for the family planning waiver program.
(2) The ((department)) agency shall submit a request to the federal
department of health and human services to amend the current family
planning waiver program as follows:
(a) Provide coverage for sexually transmitted disease testing and
treatment;
(b) Return to the eligibility standards used in 2005 including, but
not limited to, citizenship determination based on declaration or
matching with federal social security databases, insurance eligibility
standards comparable to 2005, and confidential service availability for
minors and survivors of domestic and sexual violence; and
(c) Within available funds, increase income eligibility to two
hundred fifty percent of the federal poverty level, to correspond with
income eligibility for publicly funded maternity care services.
Sec. 48 RCW 74.09.660 and 2003 1st sp.s. c 29 s 8 are each
amended to read as follows:
Each of the state's area agencies on aging shall implement a
program intended to inform and train persons sixty-five years of age
and older in the safe and appropriate use of prescription and
nonprescription medications. To further this purpose, the
((department)) agency shall award development grants averaging up to
twenty-five thousand dollars to each of the agencies upon a showing
that:
(1) The area agency on aging has the ability to effectively
administer such a program, including an understanding of the relevant
issues and appropriate outreach and follow-up;
(2) The area agency on aging can bring resources to the program in
addition to those funded by the grant; and
(3) The program will be a collaborative effort between the agency
and other health care programs and providers in the location to be
served, including doctors, pharmacists, and long-term care providers.
Sec. 49 RCW 74.09.700 and 2001 c 269 s 1 are each amended to read
as follows:
(1) To the extent of available funds and subject to any conditions
placed on appropriations made for this purpose, medical care may be
provided under the limited casualty program to persons not otherwise
eligible for medical assistance or medical care services who are
medically needy as defined in the social security Title XIX state plan
and medical indigents in accordance with eligibility requirements
established by the ((department)) agency. The eligibility requirements
may include minimum levels of incurred medical expenses. This includes
residents of nursing facilities, residents of intermediate care
facilities for the mentally retarded, and individuals who are otherwise
eligible for section 1915(c) of the federal social security act home
and community-based waiver services, administered by the department of
social and health services aging and adult services administration, who
are aged, blind, or disabled as defined in Title XVI of the federal
social security act and whose income exceeds three hundred percent of
the federal supplement security income benefit level.
(2) Determination of the amount, scope, and duration of medical
coverage under the limited casualty program shall be the responsibility
of the ((department)) agency, subject to the following:
(a) Only the following services may be covered:
(i) For persons who are medically needy as defined in the social
security Title XIX state plan: Inpatient and outpatient hospital
services, and home and community-based waiver services;
(ii) For persons who are medically needy as defined in the social
security Title XIX state plan, and for persons who are medical
indigents under the eligibility requirements established by the
((department)) agency: Rural health clinic services; physicians' and
clinic services; prescribed drugs, dentures, prosthetic devices, and
eyeglasses; nursing facility services; and intermediate care facility
services for the mentally retarded; home health services; hospice
services; other laboratory and X-ray services; rehabilitative services,
including occupational therapy; medically necessary transportation; and
other services for which funds are specifically provided in the omnibus
appropriations act;
(b) Medical care services provided to the medically indigent and
received no more than seven days prior to the date of application shall
be retroactively certified and approved for payment on behalf of a
person who was otherwise eligible at the time the medical services were
furnished: PROVIDED, That eligible persons who fail to apply within
the seven-day time period for medical reasons or other good cause may
be retroactively certified and approved for payment.
(3) The ((department)) agency shall establish standards of
assistance and resource and income exemptions. All nonexempt income
and resources of limited casualty program recipients shall be applied
against the cost of their medical care services.
Sec. 50 RCW 74.09.710 and 2007 c 259 s 4 are each amended to read
as follows:
(1) The ((department of social and health services)) agency, in
collaboration with the department of health, shall:
(a) Design and implement medical homes for its aged, blind, and
disabled clients in conjunction with chronic care management programs
to improve health outcomes, access, and cost-effectiveness. Programs
must be evidence based, facilitating the use of information technology
to improve quality of care, must acknowledge the role of primary care
providers and include financial and other supports to enable these
providers to effectively carry out their role in chronic care
management, and must improve coordination of primary, acute, and long-term care for those clients with multiple chronic conditions. The
((department)) agency shall consider expansion of existing medical home
and chronic care management programs and build on the Washington state
collaborative initiative. The ((department)) agency shall use best
practices in identifying those clients best served under a chronic care
management model using predictive modeling through claims or other
health risk information; and
(b) Evaluate the effectiveness of current chronic care management
efforts in the health and recovery services administration and the
aging and disability services administration, comparison to best
practices, and recommendations for future efforts and organizational
structure to improve chronic care management.
(2) For purposes of this section:
(a) "Medical home" means a site of care that provides comprehensive
preventive and coordinated care centered on the patient needs and
assures high quality, accessible, and efficient care.
(b) "Chronic care management" means the ((department's)) agency's
program that provides care management and coordination activities for
medical assistance clients determined to be at risk for high medical
costs. "Chronic care management" provides education and training
and/or coordination that assist program participants in improving self-management skills to improve health outcomes and reduce medical costs
by educating clients to better utilize services.
Sec. 51 RCW 74.09.715 and 2008 c 146 s 13 are each amended to
read as follows:
Within funds appropriated for this purpose, the ((department))
agency shall establish two dental access projects to serve seniors and
other adults who are categorically needy blind or disabled. The
projects shall provide:
(1) Enhanced reimbursement rates for certified dentists for
specific procedures, to begin no sooner than July 1, 2009;
(2) Reimbursement for trained medical providers for preventive oral
health services, to begin no sooner than July 1, 2009;
(3) Training, development, and implementation through a partnership
with the University of Washington school of dentistry;
(4) Local program coordination including outreach and case
management; and
(5) An evaluation that measures the change in utilization rates and
cost savings.
Sec. 52 RCW 74.09.725 and 2006 c 367 s 8 are each amended to read
as follows:
The ((department)) agency shall provide coverage for prostate
cancer screening under this chapter, provided that the screening is
delivered upon the recommendation of the patient's physician, advanced
registered nurse practitioner, or physician assistant.
Sec. 53 RCW 74.09.730 and 2009 c 538 s 1 are each amended to read
as follows:
In establishing Title XIX payments for inpatient hospital services:
(1) To the extent funds are appropriated specifically for this
purpose, and subject to any conditions placed on appropriations made
for this purpose, the ((department of social and health services))
agency shall provide a disproportionate share hospital adjustment
considering the following components:
(a) A low-income care component based on a hospital's medicaid
utilization rate, its low-income utilization rate, its provision of
obstetric services, and other factors authorized by federal law;
(b) A medical indigency care component based on a hospital's
services to persons who are medically indigent; and
(c) A state-only component, to be paid from available state funds
to hospitals that do not qualify for federal payments under (b) of this
subsection, based on a hospital's services to persons who are medically
indigent;
(2) The payment methodology for disproportionate share hospitals
shall be specified by the ((department)) agency in regulation.
Sec. 54 RCW 74.09.755 and 1989 c 427 s 12 are each amended to
read as follows:
The ((department)) agency shall prepare and request a waiver under
section 1915(c) of the federal social security act to provide community
based long-term care services to persons with AIDS or AIDS-related
conditions who qualify for the medical assistance program under RCW
74.09.510 or the limited casualty program for the medically needy under
RCW 74.09.700. Respite services shall be included as a service
available under the waiver.
Sec. 55 RCW 74.09.790 and 1993 c 407 s 9 are each amended to read
as follows:
Unless the context clearly requires otherwise, the definitions in
this section apply throughout RCW 74.09.760 through 74.09.820 and
74.09.510:
(1) "At-risk eligible person" means an eligible person determined
by the ((department)) agency to need special assistance in applying for
and obtaining maternity care, including pregnant women who are
substance abusers, pregnant and parenting adolescents, pregnant
minority women, and other eligible persons who need special assistance
in gaining access to the maternity care system.
(2) "County authority" means the board of county commissioners,
county council, or county executive having the authority to participate
in the maternity care access program or its designee. Two or more
county authorities may enter into joint agreements to fulfill the
requirements of this chapter.
(3) (("Department" means the department of social and health
services.)) "Eligible person" means a woman in need of maternity care or
a child, who is eligible for medical assistance pursuant to this
chapter or the prenatal care program administered by the ((
(4)department))
agency.
(((5))) (4) "Maternity care services" means inpatient and
outpatient medical care, case management, and support services
necessary during prenatal, delivery, and postpartum periods.
(((6))) (5) "Support services" means, at least, public health
nursing assessment and follow-up, health and childbirth education,
psychological assessment and counseling, outreach services, nutritional
assessment and counseling, needed vitamin and nonprescriptive drugs,
transportation, family planning services, and child care. Support
services may include alcohol and substance abuse treatment for pregnant
women who are addicted or at risk of being addicted to alcohol or drugs
to the extent funds are made available for that purpose.
(((7))) (6) "Family planning services" means planning the number of
one's children by use of contraceptive techniques.
Sec. 56 RCW 74.09.800 and 1993 c 407 s 10 are each amended to
read as follows:
The ((department)) agency shall, consistent with the state budget
act, develop a maternity care access program designed to ensure healthy
birth outcomes as follows:
(1) Provide maternity care services to low-income pregnant women
and health care services to children in poverty to the maximum extent
allowable under the medical assistance program, Title XIX of the
federal social security act;
(2) Provide maternity care services to low-income women who are not
eligible to receive such services under the medical assistance program,
Title XIX of the federal social security act;
(3) By January 1, 1990, have the following procedures in place to
improve access to maternity care services and eligibility
determinations for pregnant women applying for maternity care services
under the medical assistance program, Title XIX of the federal social
security act:
(a) Use of a shortened and simplified application form;
(b) Outstationing ((department)) agency staff to make eligibility
determinations;
(c) Establishing local plans at the county and regional level,
coordinated by the ((department)) agency; and
(d) Conducting an interview for the purpose of determining medical
assistance eligibility within five working days of the date of an
application by a pregnant woman and making an eligibility determination
within fifteen working days of the date of application by a pregnant
woman;
(4) Establish a maternity care case management system that shall
assist at-risk eligible persons with obtaining medical assistance
benefits and receiving maternity care services, including
transportation and child care services;
(5) Within available resources, establish appropriate reimbursement
levels for maternity care providers;
(6) Implement a broad-based public education program that stresses
the importance of obtaining maternity care early during pregnancy;
(7) Refer persons eligible for maternity care services under the
program established by this section to persons, agencies, or
organizations with maternity care service practices that primarily
emphasize healthy birth outcomes;
(8) Provide family planning services including information about
the synthetic progestin capsule implant form of contraception, for
twelve months immediately following a pregnancy to women who were
eligible for medical assistance under the maternity care access program
during that pregnancy or who were eligible only for emergency labor and
delivery services during that pregnancy; and
(9) Within available resources, provide family planning services to
women who meet the financial eligibility requirements for services
under subsections (1) and (2) of this section.
Sec. 57 RCW 74.09.810 and 1989 1st ex.s. c 10 s 6 are each
amended to read as follows:
(1) The ((department)) agency shall establish an alternative
maternity care service delivery system, if it determines that a county
or a group of counties is a maternity care distressed area. A
maternity care distressed area shall be defined by the ((department))
agency, in rule, as a county or a group of counties where eligible
women are unable to obtain adequate maternity care. The ((department))
agency shall include the following factors in its determination:
(a) Higher than average percentage of eligible persons in the
distressed area who receive late or no prenatal care;
(b) Higher than average percentage of eligible persons in the
distressed area who go out of the area to receive maternity care;
(c) Lower than average percentage of obstetrical care providers in
the distressed area who provide care to eligible persons;
(d) Higher than average percentage of infants born to eligible
persons per obstetrical care provider in the distressed area; and
(e) Higher than average percentage of infants that are of low birth
weight, five and one-half pounds or two thousand five hundred grams,
born to eligible persons in the distressed area.
(2) If the ((department)) agency determines that a maternity care
distressed area exists, it shall notify the relevant county authority.
The county authority shall, within one hundred twenty days, submit a
brief report to the ((department)) agency recommending remedial action.
The report shall be prepared in consultation with the ((department))
agency and its local community service offices, the local public health
officer, community health clinics, health care providers, hospitals,
the business community, labor representatives, and low-income advocates
in the distressed area. A county authority may contract with a local
nonprofit entity to develop the report. If the county authority is
unwilling or unable to develop the report, it shall notify the
((department)) agency within thirty days, and the ((department)) agency
shall develop the report for the distressed area.
(3) The ((department)) agency shall review the report and use it,
to the extent possible, in developing strategies to improve maternity
care access in the distressed area. The ((department)) agency may
contract with or directly employ qualified maternity care health
providers to provide maternity care services, if access to such
providers in the distressed area is not possible by other means. In
such cases, the ((department)) agency is authorized to pay that portion
of the health care providers' malpractice liability insurance that
represents the percentage of maternity care provided to eligible
persons by that provider through increased medical assistance payments.
Sec. 58 RCW 74.09.820 and 1989 1st ex.s. c 10 s 7 are each
amended to read as follows:
To the extent that federal matching funds are available, the
((department)) agency or the department of health ((if one is created))
shall establish, in consultation with the health science programs of
the state's colleges and universities, and community health clinics, a
loan repayment program that will encourage maternity care providers to
practice in medically underserved areas in exchange for repayment of
part or all of their health education loans.