PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Purpose: The department is adopting amended and new rules to improve readability, clarify policy regarding emergency transportation services, and streamline program administration by making MAA's policy more consistent with Medicare's policy where practicable.
Citation of Existing Rules Affected by this Order: Amending WAC 388-546-0001, 388-546-0100, 388-546-0150, 388-546-0200, 388-546-0250, 388-546-0300, 388-546-0400, 388-546-0450, 388-546-0500, 388-546-0600, 388-546-0700, 388-546-0800, and 388-546-1000.
Statutory Authority for Adoption: RCW 74.04.057, 74.08.090, and 74.09.510.
Adopted under notice filed as WSR 04-12-103 on June 2, 2004.
Changes Other than Editing from Proposed to Adopted Version: The following changes, other than editing changes,
have been made to the rules as proposed (Additions indicated
by underlined text, deletions indicated by strikethrough
text):
REVISED SECTIONS:
WAC 388-546-0001 Definitions. "Bordering area city hospital"
means a licensed hospital in a designated bordering city (see
WAC 388-501-0175).
WAC 388-546-2500 Transportation to or from out-of-state
treatment facilities--Coordination of benefits. (1) The
medical assistance administration (MAA) does not pay for a
client's transportation to or from an out-of-state treatment
facility when the medical service, treatment, or procedure
sought by the client is available from an in-state facility or
in a designated bordering city, whether or not the client has
other insurance coverage.
(2) For clients who are otherwise eligible for out-of-state coverage under WAC 388-546-0150, but have other third-party insurance, MAA does not pay for transportation to or from out-of-state treatment facilities when the client's primary insurance:
(a) Denies the client's request for medical services out-of-state for lack of medical necessity; or
(b) Denies the client's request for transportation for lack of medical necessity.
(3) For clients who are otherwise eligible for out-of-state coverage under WAC 388-546-0150, but have other third-party insurance, MAA does not consider requests for transportation to or from out-of-state treatment facilities unless the client has tried all of the following:
(a) Requested coverage of the benefit from his/her primary insurer and been denied;
(b) Appealed the denial of coverage by the primary insurer; and
(c) Exhausted his/her administrative remedies through the primary insurer.
(4) If MAA authorizes transportation to or from an out-of-state treatment facility for a client with other third-party insurance, MAA's liability is limited to the cost of the least costly means of transportation that does not jeopardize the client's health, as determined by MAA in consultation with the client's referring physician.
(5) For clients eligible for out-of-state coverage but have other third-party insurance, MAA considers requests for transportation to or from out-of-state treatment facilities under the provisions of WAC 388-501-0165.
A final cost-benefit analysis is available by contacting Wendy Boedigheimer, P.O. Box 45533, Olympia, WA 98504-5533, phone (360) 725-1306, fax (360) 586-9727, e-mail boediwl@dshs.wa.gov.
Number of Sections Adopted in Order to Comply with Federal Statute: New 1, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 5, Amended 13, 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 6, Amended 13, Repealed 0.
Date Adopted: August 13, 2004.
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit
Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 04-18 issue of the Register.