Preproposal statement of inquiry was filed as WSR 05-06-119.
Title of Rule and Other Identifying Information: The HIV early intervention program, this rule is the result of SHB 1275 (now RCW 43.70.670) passed during the 2003 legislative session that repealed the Department of Social and Health Services' acquired human immunodeficiency program (formerly under RCW 74.09.757). The program was reauthorized in the Department of Health under RCW 43.70.670 and was renamed the human immunodeficiency virus health insurance program. SHB 1275 also requires the Department of Health to adopt rules for implementation.
Hearing Location(s): Department of Health, Creekside Three at Centerpoint, 20435 72nd Avenue South, Suite 200, Kent, WA, on October 11, 2005, at 1:00 p.m.
Date of Intended Adoption: October 18, 2005.
Submit Written Comments to: Anne Stuyvesant, Department of Health, P.O. Box 47841, Olympia, WA 98501, e-mail http://www3.doh.wa.gov/policyreview, fax (360) 664-2216, by October 10, 2005.
Assistance for Persons with Disabilities: Contact Sheila Ichita by October 4, 2005, TTY (711) 1-800-833-6388 or (360) 236-3426.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The HIV client services program of the Department of Health is revising chapter 246-130 WAC to achieve two goals:
1. To establish rules as authorized under RCW 43.70.670.
2. To update and clarify existing rule language.
Reasons Supporting Proposal: The proposal clarifies to clients, providers and contractors the administrative requirements of the program. This rule change is necessary to comply with the 2003 legislative changes.
Statutory Authority for Adoption: RCW 43.70.670.
Statute Being Implemented: RCW 43.70.670.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Washington State Department of Health, governmental.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Anne Stuyvesant, Department of Health, Mailstop 7841, Olympia, WA 98504-7841, (360) 236-3477.
No small business economic impact statement has been prepared under chapter 19.85 RCW. This rule is exempt from the small business economic impact statement requirements under RCW 19.85.030 (1)(a) because the rule does not impose any costs and [on] the industry, and it is exempt under RCW 19.85.025(3), because the rule adopts without material change other Washington state rules, and state law per RCW 34.05.310 (4)(c).
A cost-benefit analysis is not required under RCW 34.05.328. Per RCW 34.05.328 (5)(b)(ii), cost benefit analysis is not required for rules relating only to internal governmental operations that are not subject to violation by a nongovernmental party.
September 7, 2005
Mary C. Selecky
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
INFECTION INTERVENTIONS)) EARLY INTERVENTION PROGRAM
The early intervention program provides treatment of HIV
infection to eligible clients based on available funds. The
department provides these early intervention services to
the)) public health by treating people living with
HIV, its complications, and side effects of HIV treatment, and
in order to decrease the risk of clients with HIV infecting
others. Information on how to contact this program is in WAC 246-130-090.
[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-001, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-001, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-001, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-010, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-010, filed 10/26/87.]
(1) "AIDS" means acquired immunodeficiency syndrome.
(2) "Applicant" means a person applying for early intervention program services.
(3) "Benefits manager" means:
(a) The pharmacy benefits manager contracted with the department to provide prescription drug claim processing and formulary management services; or
(b) The insurance benefits manager contracted with the department to provide insurance premium assistance through the HIV insurance program and the premium assistance program.
(4) "Client" means a person ((
determined to be)) who the
department determines is currently eligible (( by the
department)) for early intervention program services.
(4))) (5) "Department" means the Washington state
department of health.
(5))) (6) "Early intervention program services" means
medically necessary treatment and services that reduce the
rate of progression of HIV infection and HIV transmission. This includes behavioral risk reduction interventions. See
WAC 246-130-020 for details.
(6))) (7) "Federal poverty level" means the official
income level for poverty released by the federal government
each year in February.
(7))) (8) "Formulary" means the list of prescription
drugs that the early intervention program will pay for. To
obtain a copy of that list, see WAC 246-130-090.
(8))) (9) "HIV" means human immunodeficiency virus as
defined in RCW 70.24.017(7).
(10) "HIV insurance program" means the program that provides health insurance coverage for individuals with HIV who are not eligible for medical assistance programs from the department of social and health services. Medical assistance program is defined in RCW 74.9.010(8). Individuals must meet the eligibility requirements established by the department.
(9))) (11) "Medical assistance administration (MAA)"
means the part of the department of social and health services
responsible for operating the state's Medicaid and related
(10))) (12) "Premium assistance program" means the
program that pays premiums for department clients receiving
Medicare and who are enrolled in the prescription drug
(13) "Provider" means a health care professional
contracted by the department to supply ((
medical, dental, or laboratory services to a client.
(11))) (14) "Schedule of services" means the
department's list of medical, dental, and laboratory services
covered by its early intervention program. To obtain a copy
of that list, see WAC 246-130-090.
(12))) (15) "Standard of care" means treatment for HIV
that is commonly accepted by the local medical community.
(13))) (16) "Steering committee" means the department's
(( HIV)) early intervention steering committee. This advisory
committee serves at the pleasure of the (( DOH)) department
secretary (( per)) in accordance with RCW 43.70.040(2)(( ,)).
The committee consists of Washington state residents living
with HIV (( and)), HIV medical experts, and representatives
from community organizations(( , and)). The steering committee
advises the department on its early intervention program. Its
bylaws are available from the department (( per)) in WAC 246-130-090.
[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-010, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-010, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), § 246-130-010, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-010, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-015, filed 8/17/90, effective 9/17/90.]
(1) The department decides what specific medical,
laboratory, dental, ((
and)) prescription medication and
insurance services to cover after actively consulting with its
steering committee and considering:
(a) Support of the steering committee((
, which represents
clients and local medical HIV/AIDS communities));
(b) FDA approval ((
())for prescription medications(( )));
Recognition)) Standard of care recognized by the
medical community (( as a standard of care));
(d) Effectiveness in treatment for HIV, complications of HIV, side effects of current treatments for HIV or support for HIV treatment adherence; and
(e) Relative cost of services.
(2) The early intervention program services described in this section are available to all clients, unless they receive those services from other sources. Specific services of this section are available for a client only when medically necessary to treat HIV and associated diseases, complications of treating HIV, or support for HIV treatment adherence.
(3) Specific covered medical, laboratory, and dental services are listed in the department's "schedule of services."
(4) Prescription drugs covered are listed in the department's "early intervention drug formulary."
Covered health)) HIV insurance program includes:
(a) Premium payment((
, including COBRA premiums)) or
assistance as authorized in RCW 43.70.670;
(b) Deductible payment up to ((
five hundred dollars per))
a limit determined by the early intervention program within a
twelve-month period; and
(c) Co-pay payment for third-party insurance, except basic health plan, as follows:
(i) The percentage of prescription medication costs covered by the department and not covered by third-party insurers; and
(ii) Fixed dollar co-pay required by a client's third-party insurance plan for prescription medication covered by the early intervention program.
(d) For basic health plan enrollees, the department
pays the percentage of prescription medication expenses not
covered by the basic health plan but covered by the
department's early intervention program formulary.))
(6) Premium assistance program will pay premiums, co-payment and deductibles for early intervention program clients on Medicare who request assistance for the prescription drug program.
(7) The department may also coordinate other services to
treat HIV and AIDS. These are available as funding and
contracting permit. For example, as of July 1, 2000, the
department may pay toward the spend-down for MAA medically
needy (MN) clients who are also ((
DOH)) early intervention
program clients(( , up to one thousand one hundred dollars per
(7))) (8) The early intervention program will provide
written notification to clients, providers, and the steering
committee at least thirty days in advance of any reduction in
service or payments.
(9) You may contact the department per WAC 246-130-090 to make comments on service coverage or to receive information.
[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-020, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-020, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-020, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-020, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-020, filed 10/26/87.]
(1) The department pays a provider((
s)) or benefits
manager who contracts with the department for services
described in WAC 246-130-020.
(a) The department will only pay for services delivered by a contracted provider or benefits manager.
Services must be billed within one hundred eighty
days of being provided.
(2))) A provider or benefits manager must bill the department according to the procedure and terms of the contract.
(c) The department only pays for covered, medically necessary early intervention program services delivered to clients who are eligible under WAC 246-130-040.
(3))) (2) Payment of services depends on availability
of federal and state funds. The department will not deny
payment of any individual claim for funding availability
unless the department denies an entire class of claims, or an
(a) Providers and clients will receive written notice
of any limitation or reduction in coverage or payment that
results from loss of federal or state funding at least thirty
days in advance.
(b) If the department denies or reduces payment for any class of claims or program, it must only show that it made a good faith effort to mail written notice to all providers and clients.
(4))) (3) A provider((
s)) or benefits manager who
disputes a payment may do so through the contracts process(( . See)) specified in WAC 246-130-080(3).
(5) Providers must bill the department per terms of the
contract between the provider and department.
(6))) (4) The department is payer of last resort.
(a) A provider((
s)) or benefits manager must bill all
other third-party sources prior to billing the department for
covered services(( ,)); and
(b) A provider((
s)) or benefits manager must reimburse
the department for any funds paid by the department, which are
payable by other sources.
[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-030, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-030, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), § 246-130-030, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-030, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-030, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-030, filed 10/26/87.]
(2) An applicant is eligible for twelve months of early
intervention program services ((
when)) beginning the first of
the month that the applicant's completed application was
(3) The department requires the following documentation:
The applicant has)) A medical diagnosis of HIV
(( (the department may require a doctor's diagnosis)));
The applicant has)) A Washington state address
(( and intends to stay in Washington state));
The applicant or his/her designated representative
has submitted truthful information on the department's
application form to the department;
(d) The applicant has monthly)) Verification of income,
averaged over twelve months,)) that is equal to or less than
the limit set by (( DOH in consultation with)) the early
intervention program (( steering committee. For example: In
2000, that limit was three hundred seventy percent of Federal
Poverty Level for one person ($2,575) per month. The
department shall announce and seek public comment on proposed
changes to the income limit)). Income includes:
(i) Wages, salary, overtime, tips, and bonuses;
(ii) Social Security, trust funds for disability, or other disability insurance payments;
(iii) Unemployment benefits;
(iv) Veteran's Administration benefits;
(v) Lump sum payments of gifts, cash inheritance, property, lottery winnings, worker's compensation for lost income, or severance pay;
(vi) Private pensions, annuities, or royalties; and
(vii) Investment dividends.
(e))) (4) The (( applicant has)) department also
considers the following when determining client eligibility:
(a) Client resources: A client must have current
resources of less than ((
ten thousand dollars)) or equal to
the limit set by the early intervention program. Resources
include trust funds, and any other financial resources
available to the applicant. The department does not count the
following as resources:
(i) One home, defined as real property owned by the client as his or her principal place of residence in Washington state, together with surrounding property not to exceed five acres;
(ii) Commercial property, or property used for producing income, up to the first twenty thousand dollars of value;
(iii) Household furnishings;
(iv) One automobile; or
(v) Pensions and other Internal Revenue Service designated retirement accounts; or
(f) The applicant is not currently eligible for or
cannot access)) (vi) Burial plots or prepaid funeral
(b) Client ineligibility for medical benefits ((
through the department of social and health services(( ; and
(g) The applicant is not currently an inmate of any correctional institute or jail or will not be when their application is approved.
(2) Periods of eligibility caused by false information may cause the department to:
(a) Disenroll a client from the department's early intervention program; and
(b) Recover funds paid by the department during periods of false eligibility)). If a client is eligible for medical benefits through the department of social and health services, he or she may not qualify for the early intervention program, except when the department is coordinating other services as specified in WAC 246-130-020(6).
(5) Individuals transitioning from any correctional institute are eligible for service that will assist them to access medication once they are released from the facility.
(6) Refer to the HIV client services webpage through DOH WEB (A-Z) at www.doh.wa.gov.
[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-040, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-040, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), § 246-130-040, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-040, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-040, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-040, filed 10/26/87.]
(2) Clients who do not notify the department of changes may be disenrolled and required to repay the funds spent on their services.
(3) Clients may be disenrolled from the program if they provide false information.
(1))) Applicant and client information supplied to the
department)) early intervention program is confidential.
The early intervention program follows all applicable state
and federal laws regarding the exchange of medical
(2) Applicants must provide medical and financial
information at the department's request, including:
(a) Sources and amounts of all income and resources;
(b) Evidence that all resources or entitlements available to an applicant were accessed before that applicant applied for or received early intervention program services; and
(c) Other medical or financial information.
(3) Clients must notify the department of medical or financial changes that affect their eligibility within twenty days of the change. Clients who do not notify the department of medical or financial changes must pay back to the department funds provided during the period of ineligibility caused by those changes.))
[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-060, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-060, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-060, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-060, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-060, filed 10/26/87.]
(1) Chapter 246-10 WAC details the ((
proceeding)) adjudication process for matters involving
receipt of benefits. The department will provide information
on the cause for denied benefits, how a proceeding may be
requested, the forms necessary to request a proceeding and
information on required time frames.
(2) Applicants and clients may not appeal the
department's denial or limitations when the department
closes)) discontinues or limits an early intervention
program service (( due)) to either funding availability or
federal or state law or rule changes. See WAC 246-130-030(3)
for more details.
(3) Rate and payment disputes between a provider((
benefits manager and the department are handled by contract.
(4) Clients of any other public agency must use that
agency's process to resolve eligibility or other disputes
regarding that agency. ((
MAA's fair hearings process is
described in chapter 388-08 WAC.))
[Statutory Authority: RCW 43.70.040. and RCW 43.70.120. 00-19-117, § 246-130-080, filed 9/20/00, effective 10/21/00.]
Department of Health
P.O. Box 47841
Olympia, WA 98504-7841
1-800-272-2437)) 1-877-376-9316 Option 2
Or, visit the WEB site at www.doh.wa.gov. ((
"HIV Information" accesses information about the early
intervention program.)) Locate HIV client services through the
"DOH WEB (A-Z)" at www.doh.wa.gov.
[Statutory Authority: RCW 43.70.040. and RCW 43.70.120. 00-19-117, § 246-130-090, filed 9/20/00, effective 10/21/00.]
The following section of the Washington Administrative Code is repealed:
|WAC 246-130-028||What services are not available?|