SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: June 28, 1999.
Purpose: To eliminate duplication by consolidating certain information into a single section and update rule content to reflect current department policy. To comply with the Governor's Executive Order 97-02.
Citation of Existing Rules Affected by this Order: Amending WAC 388-550-2800, 388-550-2900, 388-550-3450, 388-550-3500, 388-550-3900, and 388-550-4100.
Statutory Authority for Adoption: RCW 74.09.090, 42 U.S.C. 1395x(v) and 1396r-4, 42 C.F.R. 447.271, 11303, and 2652.
Adopted under notice filed as WSR 99-09-091 on April 21, 1999.
Changes Other than Editing from Proposed to Adopted Version: WAC 388-550-3500 added "...as determined by the legislature and as addressed in subsequent budget notes. MAA does not...." This was necessary because of legislative budget notes which define the senate budget bill clarify which inflation adjustment should be used.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 6, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 6, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 6, Repealed 0.
Other Findings Required by Other Provisions of Law as Precondition to Adoption or Effectiveness of Rule: Per RCW 34.05.380(3), the rule must become effective July 1, 1999, because the senate budget bill (ESSB 5180) and the budget notes defining the budget bill mandate this effective date.Effective Date of Rule: July 1, 1999.
June 28, 1999
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit2552.6
(1) MAA pays hospitals for inpatient hospital services using the rate setting methods identified in the department’s approved state plan that includes:
|Negotiated conversion factor||Hospitals participating in the
|Cost-based conversion factor||Hospitals not participating in or exempt from the Medicaid hospital selective contracting program (DRG method)|
|Ratio of costs-to-charges||Hospitals ((
|Fixed per diem rate||Acute Physical Medicine and Rehabilitation (Acute PM&R) Level B contracted facilities|
(3) MAA’s annual aggregate payments for inpatient hospital services, including ((
aggregate payments to)) state-operated hospitals, must not exceed estimated amounts that MAA
would have (( been)) paid (( under the)) using Medicare payment principles.
(4) When hospital ownership changes, MAA’s payment to the hospital must not exceed
the amount allowed under 42 U.S.C. Section ((
1385x)) 1395x (v)(1)(O).
(5) Hospitals participating in the medical assistance program must annually submit to the department:
(a) A copy of the hospital’s HCFA 2552 ((
uniform)) Medicare Cost Report; and
(b) A disproportionate share hospital application.
(6) Reports referred to in subsection (5) of this section must be completed according to:
(a) Medicare's cost reporting requirements;
(b) The provisions of this chapter; and
(c) Instructions issued by MAA.
Unless federally or state-regulated, providers must)) MAA requires hospitals to
follow generally accepted accounting principles unless federally or state-regulated.
(8) Participating ((
providers)) hospitals must permit MAA to conduct periodic audits of
their financial and statistical records.
(9) Payments for trauma services may be enhanced per WAC ((
[Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652. 99-06-046, § 388-550-2800, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-2800, filed 12/18/97, effective 1/18/98.]
(1) The department pays covered inpatient hospital services only to:
(a) General hospitals that meet the definition in RCW 70.41.020;
(b) Inpatient psychiatric facilities and alcohol or drug treatment centers:
(i) Approved by the department; and
(ii) Not paid directly through the ((
regional support networks)) RSNs.
(c) Out-of-state ((
hospital providers)) hospitals, subject to conditions specified in WAC 388-550-6700.
(2) MAA does not pay for hospital care and/or services provided to ((
a)) an MAA client
enrolled with a (( MAA-contracted)) managed care (( carrier. An exception is when MAA
specifically authorized the provision of and payment for a service not covered by the health
carrier's capitation contract but covered under the client's medical assistance program)) plan,
when the plan covers those services. Plans have the authority to determine the treatment regimen
of coverage as long as they cover all the Medicaid services that MAA reimburses them to cover.
Plans may also provide coverage of services beyond that for which Medicaid reimburses them.
(3) MAA does not pay a hospital for care or services provided to a client enrolled in the
hospice program, except as provided under chapter 388-551 WAC ((
subchapter I, Hospice services.
(4) MAA does not pay hospitals for inpatient ancillary services in addition to the
diagnosis-related group ())DRG(( ))) payment. The DRG payment includes ancillary services
(( which)) that include, but are not limited to, the following:
(a) Laboratory services;
(b) Diagnostic X-ray and other imaging services, including, but not limited to, magnetic resonance imaging, magnetic resonance angiography, computerized axial tomography, and ultrasound;
(c) Drugs and pharmacy services;
(d) Respiratory therapy and related services;
(e) Physical therapy and related services;
(f) Occupational therapy;
(g) Speech therapy and related services;
(h) Durable medical equipment and medical supplies, including infusion equipment and supplies;
(i) Prosthetic devices used during the client's hospital stay or permanently implanted during the hospital stay, such as artificial heart or replacement hip joints; and
(j) Service charges for handling and processing blood or blood derivatives.
(5) Neither MAA nor the client is responsible for payment for additional days of hospitalization when:
(a) A client exceeds the professional activities study (PAS) length of stay (LOS) limitations; and
(b) The provider has not obtained MAA approval for the LOS extension, as specified in WAC 388-550-1700(4).
(6) The LOS limit for a hospitalization is the seventy-fifth percentile of the PAS length of stay for that diagnosis code or combination of codes, published in the PAS Length of Stay-Western Region edition, as periodically updated.
(7) Neither MAA nor the client is responsible for payment of elective or nonemergent
inpatient services which are included in MAA’s selective contracting program and ((
which a client receives in a nonparticipating hospital in a selective contracting area (SCA) unless
the provider received prior approval from MAA as required by WAC 388-550-1700 (2)(a). The
client, however, may be held responsible for payment of such services if (( he or she)) the client
contracts in writing with the hospital at least seventy-two hours in advance of the hospital
admission to be responsible for payment. See WAC 388-550-4600, Selective contracting
(8) MAA may consider hospital stays of twenty-four hours or less short stays, and does
not pay such stays under the DRG methodology((
, except that)). The exception for stays of
twenty-four hours or less involving the following situations are paid under the DRG system:
(a) Death of a client;
(b) Obstetrical delivery;
(c) Initial care of a newborn; or
(d) Transfer of a client to another acute care hospital.
(9)(a) Under the ratio of costs-to-charges (RCC) method, MAA does not pay for inpatient hospital services provided more than one day prior to the date of a scheduled or elective surgery. These services must not be charged to the client.
(b) Under the DRG method, MAA ((
deems)) considers all services provided (( prior to))
the day before a scheduled or elective surgery to be included in the hospital's DRG payment for
(c) MAA does not count toward the threshold for hospital outlier status:
(i) Any charges for extra days of inpatient stay prior to a scheduled or elective surgery; and
(ii) The associated services provided during those extra days.
(10) MAA applies the following rules to RCC cases and high-cost DRG outlier cases for
over)) that exceed the high-cost outlier threshold:
(a) MAA covers hospital stat charges only for specific laboratory procedures determined
and published by MAA as qualified stat procedures. ((
MAA does not automatically treat)) Tests
generated in the emergency room (( as justifying)) do not automatically justify a stat order.
(b) MAA pays hospitals for special care charges only when:
(i) The hospital has a department of health (DOH) or Medicare-((
special care unit;
(ii) The special care service being billed, such as intensive care, coronary care, burn unit, psychiatric intensive care, or other special care, was provided in the special care unit;
(iii) The special care service provided is the kind of service for which the special care unit
has been DOH- or Medicare-((
(iv) The client's medical condition required the care be provided in the special care unit.
(11) MAA determines its actual payment for a hospital admission by deducting from the
basic hospital ((
payment)) reimbursement amount those charges which are the client's
responsibility(( ,)) (referred to as spend-down(( , or a))) and any third party(( 's)) liability.
(12) MAA reduces reimbursement rates to hospitals for services provided to
medical care services))GAU clients according to the (( individual)) hospital(( 's)) specific
ratable and/or equivalency factors, as provided in WAC 388-550-4800.
(13) MAA pays for the hospitalization of a client who is eligible for Medicare and
Medicaid only when the client has exhausted ((
his or her)) the Medicare part A benefits,
including the nonrenewable lifetime hospitalization reserve of sixty days.
(14) MAA pays in-state and border area hospital((
s’)) accommodation charges (( are
paid)) by multiplying the hospital’s RCC rate to the lesser of the room rate submitted by the
hospital to MAA or the accommodation charges billed on the claim.
(15) MAA pays out-of-state accommodation charges at the in-state average RCC rate times the hospital’s billed charge.
(16) With regard to room rate submittals to MAA:
(a) A hospital must submit ((
to MAA)) changes on the room rate change form, DSHS
(b) Charges must not exceed the hospital’s usual and customary charges to the public as required by 42 CFR § 447.271;
(c) New room rates take effect on the effective date stated on the room rate change form, or fourteen calendar days after MAA receives the form, whichever is later;
(d) MAA ((
will)) does not make retroactive room rate changes; and
(e) MAA pays private rooms ((
are paid)) at the semi-private room rate.
[Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652. 99-06-046, § 388-550-2900, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-2900, filed 12/18/97, effective 1/18/98.]
(1) For Medicaid accommodation costs, MAA:
The department shall)) Uses each hospital's base period cost data to calculate the
hospital's total operating, capital, and direct medical education costs for each of the nine
accommodation categories described in WAC 388-550-3150(5)(( .)); then
The department shall divide operating, capital, and direct medical education))
Divides those costs per category by total hospital days per category to arrive at a per day
accommodation cost(( .)); then
The department shall multiply)) Multiplies the per day accommodation cost for each
category by the total Medicaid days to arrive at total Medicaid accommodation costs per category
for the three components.
(2) For ancillary costs MAA:
The department shall also)) Uses the base period cost data to calculate total
operating, capital, and direct medical education costs for each of the hospital's twenty-nine
ancillary categories(( .)); then
The department shall)) Divides these costs by total charges per category to arrive at
a (( cost-to-charge ratio)) ratio of costs-to-charges (RCC) per ancillary category(( .)); then
The department shall multiply these cost-to-charge ratios)) Multiplies these RCCs
by Medicaid charges per category, as tracked by the Medicaid Management Information System
(MMIS), to arrive at total Medicaid ancillary costs per category for the three components
(operating, capital, and medical education).
The department shall combine)) MAA:
(a) Combines Medicaid accommodation and ancillary costs to derive the hospital's total
costs for operating, capital, and direct medical education components for the base year((
department shall divide these components' combined total will be divided by the number of
Medicaid cases during the base year to arrive at an average cost per DRG admission for the
(b) Divides the hospital’s combined total cost by the number of Medicaid cases during the base year to arrive at an average Medicaid cost per DRG admission; then
(c) Adjusts, for hospitals with a fiscal year ending different than the common fiscal year end, the Medicaid average cost by a factor determined by MAA to standardize hospital costs to the common fiscal year end. MAA adjust the hospital’s Medicaid average cost by the hospital’s specific case mix index.
(4) MAA caps the ((
department shall adjust the)) Medicaid average cost per (( admission
for each component to a common fiscal year end using the appropriate McGraw-Hill Data
Resources, Inc., (DRI) Prospective Payment System (PPS)-Type Hospital Market Basket update. The department shall standardize these three admission cost components by dividing the average
cost by the hospital's case-mix index.
(5)(a) For hospitals with medical education programs, the department shall remove the indirect medical education costs from operating and capital costs before the peer group cost cap is set.
(b) The department shall also remove the cost of outlier cases in accordance with WAC 388-550-3350(1).
(c))) case for peer groups B and C at seventy percent of the peer group average. In calculation of the peer group cap, MAA removes the indirect medical education and outlier costs from the Medicaid average cost per admission.
(a) For hospitals in MAA peer groups B ((
and)) or C, (( the department shall set)) MAA
determines aggregate costs for the operating, capital, and direct medical education components at
the lesser of hospital-specific aggregate cost or the peer group cost cap(( .
(6) The department shall add to the lesser of)); then
(b) To whichever is less, the hospital-specific aggregate cost or the peer group cost cap
determined in subsection ((
(5))) (4) of this section, MAA adds:
(a))) (i) The individual hospital's indirect medical education costs, as determined in
WAC 388-550-3250(2); and
(b))) (ii) An outlier cost adjustment in accordance with WAC 388-550-3350(2).
(7)(a) The department shall))
(5) For an inflation adjustment MAA may:
(a) Multiply the sum obtained in subsection ((
(6))) (4) of this section by (( the DRI
PPS-type hospital market basket update)) an inflation factor as determined by the legislature for
the period January 1 of the year after the base year through (( September 30)) October 31 of the
rebase year(( .)); then
The department shall then)) Reduce the product obtained in (a) of this subsection by
the outlier set-aside percentage determined in accordance with WAC 388-550-3350(3) to arrive
at the hospital's adjusted (( cost-based conversion factor for July 1 of the rebase year.)) CBCF;
(8) The department shall))
(c) Multiply the hospital's adjusted ((
cost-based conversion factor determined in
subsection (7) of this section)) CBCF by the applicable DRG relative weight to calculate the
DRG payment for each admission.
[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-3450, filed 12/18/97, effective 1/18/98.]
Effective on November 1 of each year, MAA may adjust(( s)) all cost-based conversion factors
(CBCF) (( for)) by an inflation (( for the following twelve months.
(2) MAA makes CBCF adjustments using the annual inflation factor from the PPS-type hospital market-basket index factor from the most recent McGraw-Hill Data Resources, Inc., (DRI) forecast.
(3) MAA considers adjustments to negotiated conversion factors according to the terms of the individual hospital's contract)) factor, as determined by the legislature and as addressed in subsequent budget notes. MAA does not automatically give an inflation increase to negotiated conversion factors for contracted hospitals participating in the hospital selective contracting program.
[Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652. 99-06-046, § 388-550-3500, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-3500, filed 12/18/97, effective 1/18/98.]
(1) Under the diagnosis-related group (DRG) payment method, ((
the department shall calculate)):
(a) MAA calculates the cost-based conversion factor (CBCF) of a border area hospital as defined in WAC 388-550-1050, in accordance with WAC 388-550-3450.
(a))) (b) For a border area hospital with (( insufficient Medicare cost report (HCFA Form
2552) data, the department shall assign a CBCF based on the peer group average final conversion
factor for its Washington hospital peer group.
(b) The department shall include in this average final conversion factor all adjustments to the CBCF, including the outlier set-aside factor described in WAC 388-550-3350(3))) no HCFA 2552 for the rebasing year, MAA assigns the MAA peer group average conversion factor. This is the average of all final conversion factors of hospitals in that group.
(a) The ratio of costs-to-charges (RCC) ((
payment method, the department shall calculate
a border area hospital's RCC)) in accordance with WAC 388-550-4500.
(b) For a border area hospital with ((
insufficient Medicare cost report ()) no HCFA
(( Form)) 2552(( ) data, the department shall assign an RCC based on the weighted average of the
RCC ratios for in-state Washington hospitals)) Medicare cost report, its RCC on the Washington
in-state average RCC ratios.
[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-3900, filed 12/18/97, effective 1/18/98.]
rate-setting purposes, ((
the department shall consider)) MAA considers as (( a)) new:
(a) A hospital ((
an entity)) which began services after the most recent (( base period used
for calculating)) rebased cost-based conversion factors (CBCFs), or
(b) A hospital that has not been in operation for a complete fiscal year.
The department shall base)) MAA determines a new hospital's (( cost-based rates on
the peer group average final conversion factor for its Washington hospital peer group. The
department shall include in this average final conversion factor all adjustments to the CBCF,
including the outlier set aside factor described in WAC 388-550-3350(3))) CBCF as the average
of the CBCF of all hospitals within the same MAA peer group.
The department shall base)) MAA determines a new hospital's ratio of
costs-to-charges (RCC) (( rates on the statewide weighted average RCC rate)) by calculating and
using the average RCC rate for all current Washington in-state hospitals.
The department shall not consider)) MAA considers that a change in hospital
ownership (( as constituting creation of)) does not constitute a new hospital.
[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-4100, filed 12/18/97, effective 1/18/98.]