WSR 07-11-129

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed May 22, 2007, 9:09 a.m. , effective August 1, 2007 ]


Effective Date of Rule: August 1, 2007.

Purpose: The purpose of these changes is to amend sections in chapter 388-550 WAC relating to the long-term acute care (LTAC) program in order to change verbiage from "medical assistance administration (MAA)" to "the department," change verbiage from "facility" to "hospital," add verbiage that special client service contracts that complement a core provider agreement for an out-of-state LTAC hospital take precedence over any conflicting payment program policies set in WAC by the department, and to clarify and update existing language for the LTAC program WAC sections, and WAC 388-550-1000.

Citation of Existing Rules Affected by this Order: Amending WAC 388-550-1000, 388-550-2565, 388-550-2570, 388-550-2575, 388-550-2580, 388-550-2590, 388-550-2595, and 388-550-2596.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.500.

Adopted under notice filed as WSR 07-08-107 on April 4, 2007.

A final cost-benefit analysis is available by contacting Larry Linn, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1856, fax (360) 753-9152, e-mail linnld@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 9, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 9, Repealed 0.

Date Adopted: May 14, 2007.

Stephanie E. Schiller

Rules Consultant

3843.1
AMENDATORY SECTION(Amending WSR 98-01-124, filed 12/18/97, effective 1/18/98)

WAC 388-550-1000   Applicability.   The department ((shall)) pays for hospital services provided to eligible clients when:

(1) The eligible client is a patient in ((a general)) an acute care hospital and the hospital meets the definition of hospital or psychiatric hospital in RCW 70.41.020, WAC 388-500-0005 or 388-550-1050;

(2) The services are medically necessary as defined under WAC 388-500-0005; and

(3) The conditions, exceptions and limitations in this chapter are met.

[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, 388-550-1000, filed 12/18/97, effective 1/18/98.]


AMENDATORY SECTION(Amending WSR 02-14-162, filed 7/3/02, effective 8/3/02)

WAC 388-550-2565   The long-term acute care (LTAC) program -- General.   The long-term acute care (LTAC) program is a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services provided in a ((medical assistance administration (MAA))) department-approved LTAC ((facility)) hospital during the acute phase of a client's care. ((MAA)) The department requires prior authorization for LTAC stays. See WAC 388-550-2590 for prior authorization requirements.

(1) A facility's multidisciplinary team coordinates individualized LTAC services at ((an MAA)) a department-approved LTAC ((facility)) hospital.

(2) ((MAA)) The department determines the authorized length of stay for LTAC services based on the client's need as documented in the client's medical records and the criteria described in WAC 388-550-2590.

(3) When the ((MAA)) department-authorized length of stay ends, the provider transfers the client to a more appropriate level of care or, if appropriate, discharges the client to the client's residence.

[Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2565, filed 7/3/02, effective 8/3/02.]


AMENDATORY SECTION(Amending WSR 02-14-162, filed 7/3/02, effective 8/3/02)

WAC 388-550-2570   LTAC program definitions.   The following definitions and abbreviations and those found in WAC 388-500-0005 and 388-550-1050 apply to the LTAC program.

"Level 1 services" means long-term acute care (LTAC) services provided to clients who require more than eight hours of direct skilled nursing care per day. Level 1 services include one or both of the following:

(1) Active ventilator weaning care and any specialized therapy services, such as physical, occupational, and speech therapies; or

(2) Complex medical care that may include: Care for complex draining wounds, care for central lines, multiple medications, frequent assessments and close monitoring, third degree burns that may involve grafts and/or frequent transfusions, and specialized therapy services, such as physical, occupational, and speech therapies.

"Level 2 services" means long-term acute care (LTAC) services provided to clients who require four to eight hours of direct skilled nursing care per day. Level 2 services include at least two of the following:

(1) Ventilator care for clients who are stable, dependent on a ventilator, and have complex medical needs;

(2) Care for clients who have tracheostomies, complex airway management and medical needs, and the potential for decannulation; and

(3) Specialized therapy services, such as physical, occupational, and speech therapies.

"Long-term acute care" means inpatient intensive long-term care services provided in ((MAA)) department-approved LTAC ((facilities)) hospitals to eligible medical assistance clients who require Level 1 or Level 2 services.

"Survey" or "review" means an inspection conducted by a federal, state, or private agency to evaluate and monitor a facility's compliance with LTAC program requirements.

"Transportation company" means either ((an MAA)) a department-approved transportation broker or a transportation company doing business with ((MAA)) the department.

[Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2570, filed 7/3/02, effective 8/3/02.]


AMENDATORY SECTION(Amending WSR 02-14-162, filed 7/3/02, effective 8/3/02)

WAC 388-550-2575   Client eligibility requirements for LTAC services.   Only a client who is eligible for one of the following programs may receive LTAC services, subject to the restrictions and limitations in WAC 388-550-2565, 388-550-2570, 388-550-2580, 388-550-2585, 388-550-2590, 388-550-2595, 388-550-2596, and other ((published)) rules:

(1) Categorically needy program (CNP);

(2) ((CNP -)) State children's health insurance program (((CNP-))SCHIP);

(3) Limited casualty program - medically needy program (LCP-MNP);

(4) ((CNP -)) Alien emergency medical ((only)) (AEM)(CNP); or

(5) ((LCP-MNP -)) Alien emergency medical ((only)) (AEM)(LCP-MNP).

[Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2575, filed 7/3/02, effective 8/3/02.]


AMENDATORY SECTION(Amending WSR 02-14-162, filed 7/3/02, effective 8/3/02)

WAC 388-550-2580   Requirements for becoming an LTAC ((facility)) hospital.   (1) To apply to become ((an MAA)) a department-approved LTAC ((facility)) hospital, ((MAA)) the department requires a hospital ((provider)) to:

(a) Submit a letter of request to:

LTAC Program Manager

Division of ((Medical Management)) Healthcare Services

((Medical Assistance)) Health and Recovery Services Administration

P.O. Box 45506

Olympia WA 98504-5506; and


(b) Include documentation that confirms the facility is:

(i) Medicare certified for LTAC;

(ii) Accredited by the Joint Commission on Accreditation of ((hospital)) Healthcare Organizations (JCAHO);

(iii) ((Licensed by the department of health (DOH))) For an in-state hospital licensed as an acute care hospital ((as defined)) by the department of health (DOH) under WAC 246-310-010; ((and))

(iv) ((Contracted under MAA's selective contracting program, if in a selective contracting area, unless exempted from the requirements by MAA)) For a hospital located out-of-state, licensed as an acute care hospital by that state; and

(v) Contracted with the department to provide LTAC services if the LTAC hospital is located outside the state of Washington.

(2) The hospital ((facility)) qualifies as ((an MAA)) a department-approved LTAC ((facility)) hospital when:

(a) The ((facility)) hospital meets all the requirements in this section;

(b) ((MAA's)) The department's clinical staff has conducted ((a facility)) an on-site visit; and

(c) ((MAA)) The department provides written notification that the ((facility)) hospital qualifies to be ((reimbursed)) paid for providing LTAC services to eligible medical assistance clients.

(3) ((MAA)) Department-approved LTAC ((facilities)) hospitals must meet the general requirements in chapter 388-502 WAC((, Administration of medical programs providers)).

[Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2580, filed 7/3/02, effective 8/3/02.]


AMENDATORY SECTION(Amending WSR 02-14-162, filed 7/3/02, effective 8/3/02)

WAC 388-550-2585   LTAC ((facilities)) hospitals -- Quality of care.   (1) To ensure quality of care, ((MAA)) the department may conduct post-pay or on-site reviews of any ((MAA)) department-approved LTAC ((facility)) hospital. See WAC 388-502-0240, Audits and the audit appeal process for contractors/providers, for additional information on audits conducted by department staff.

(2) A provider of LTAC services must act on any reports of substandard care or violations of the ((facility's)) hospital's medical staff bylaws. The provider must have and follow written procedures that provide a resolution to either a complaint or grievance or both.

(3) A complaint or grievance regarding substandard conditions or care may be investigated by any one or more of the following:

(a) The department of health (DOH);

(b) The Joint Commission on Accreditation of ((Hospital)) Healthcare Organizations (JCAHO);

(c) ((MAA)) The department; or

(d) Other agencies with review authority for ((MAA)) the department's programs.

[Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2585, filed 7/3/02, effective 8/3/02.]


AMENDATORY SECTION(Amending WSR 02-14-162, filed 7/3/02, effective 8/3/02)

WAC 388-550-2590   ((MAA's)) Department prior authorization requirements for Level 1 and Level 2 LTAC services.   (1) ((MAA)) The department requires prior authorization for Level 1 and Level 2 LTAC inpatient stays. The prior authorization process includes all of the following:

(a) For an initial thirty-day stay:

(i) The client must:

(A) Be eligible under one of the programs listed in WAC 388-550-2575;

(B) Meet the high cost outlier or high outlier status, respectively, at the transferring hospital as described in WAC 388-550-3700((; and)). Exception: If the claim is paid under a payment method other than the DRG or per diem payment method, the claim must meet the same outlier threshold described in WAC 388-550-3700.

(C) Require Level 1 or Level 2 LTAC services as defined in WAC 388-550-2570.

(ii) The LTAC provider of services must:

(A) Before admitting the client to the LTAC ((facility)) hospital, submit a request for prior authorization to the ((MAA)) the department's clinical consultation team by fax, electronic mail, or telephone, as published in ((MAA's)) the department's LTAC billing instructions; ((and))

(B) Include sufficient medical information to justify the requested initial stay.

(C) Receive prior authorization from the department's medical director or designee, based on clinical quality review by the department's clinical consultation team to determine the client's circumstances and the medical justification for transfer from the transferring hospital; and

(D) Meet all the requirements in WAC 388-550-2580.

(b) For extensions of stay:

(i) The client must:

(A) Be eligible under one of the programs listed in WAC 388-550-2575; and

(B) Require Level 1 or Level 2 LTAC services as defined in WAC 388-550-2570.

(ii) The LTAC provider of services must:

(A) Before the client's current authorized period of stay expires, submit a request for the extension of stay to the ((MAA)) the department's clinical consultation team by fax, electronic mail, or telephone; and

(B) Include sufficient medical information to justify the requested extension of stay.

(2) The ((MAA)) department's clinical consultation team authorizes((, in writing,)) Level 1 or Level 2 LTAC services for initial stays or extensions of stay based on the client's circumstances and the medical justification received. A client who does not agree with a decision regarding a length of stay has a right to a fair hearing under chapter 388-02 WAC. After receiving a request for a fair hearing, ((MAA)) the department may request additional information from the client and the facility, or both. After ((MAA)) the department reviews the available information, the result may be:

(a) A reversal of the initial ((MAA)) department decision;

(b) Resolution of the client's issue(s); or

(c) A fair hearing conducted per chapter 388-02 WAC.

(3) ((MAA)) The department may authorize administrative day rate ((reimbursement)) payment for a client who:

(a) Does not meet the requirements described in this section;

(b) Is waiting for placement in another hospital or other facility; or

(c) If appropriate, is waiting to be discharged to the client's residence.

[Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2590, filed 7/3/02, effective 8/3/02.]


AMENDATORY SECTION(Amending WSR 03-02-056, filed 12/26/02, effective 1/26/03)

WAC 388-550-2595   Identification of and payment methodology for services and equipment included in the LTAC fixed per diem rate.   (1) In addition to room and board, the LTAC fixed per diem rate includes, but is not limited to, the following (see ((MAA's)) the department's LTAC billing instructions for applicable revenue codes):

(a) Room and board - Rehabilitation;

(b) Room and board - Intensive care;

(c) Pharmacy - Up to and including two hundred dollars per day in total allowed covered charges for any combination of pharmacy services that includes prescription drugs, total parenteral nutrition (TPN) therapy, IV infusion therapy, and/or epogen/neupogen therapy;

(d) Medical/surgical supplies and devices;

(e) Laboratory - General;

(f) Laboratory - Chemistry;

(g) Laboratory - Immunology;

(h) Laboratory - Hematology;

(i) Laboratory - Bacteriology and microbiology;

(j) Laboratory - Urology;

(k) Laboratory - Other laboratory services;

(l) Respiratory services;

(m) Physical therapy;

(n) Occupational therapy; and

(o) Speech-language therapy.

(2) ((MAA)) The department pays the LTAC ((facility)) hospital for services covered by the LTAC fixed per diem rate by the rate in effect at the ((time the LTAC services are provided)) date of admission, minus the sum of:

(a) Client liability, whether or not collected by the provider; and

(b) Any amount of coverage from third parties, whether or not collected by the provider, including, but not limited to, coverage from:

(i) Insurers and indemnitors;

(ii) Other federal or state ((medical care)) healthcare programs;

(iii) Payments made to the provider on behalf of the client by individuals or organizations not liable for the client's financial obligations; and

(iv) Any other contractual or legal entitlement of the client, including, but not limited to:

(A) Crime victims' compensation;

(B) Workers' compensation;

(C) Individual or group insurance;

(D) Court-ordered dependent support arrangements; and

(E) The tort liability of any third party.

(3) ((MAA)) The department may make annual rate increases to the LTAC fixed per diem rate by using ((the same inflation factor and date of rate increase that MAA uses for acute care hospital diagnostic-related group (DRG) rates. This DRG rate adjustment method is described in WAC 388-550-3450(5))) a vendor rate increase. The department may rebase the LTAC fixed per diem rate periodically.

(4) When the department establishes a special client service contract to complement the core provider agreement with an out-of-state LTAC hospital for services, the contract terms take precedence over any conflicting payment program policies set in WAC by the department.

[Statutory Authority: RCW 74.08.090. 03-02-056, 388-550-2595, filed 12/26/02, effective 1/26/03; 02-14-162, 388-550-2595, filed 7/3/02, effective 8/3/02.]


AMENDATORY SECTION(Amending WSR 06-24-036, filed 11/30/06, effective 1/1/07)

WAC 388-550-2596   Services and equipment covered by the department but not included in the LTAC fixed per diem rate.   (1) The department uses the ratio of costs-to-charges (RCC) payment method to ((reimburse)) pay an LTAC ((facility)) hospital for the following that are not included in the LTAC fixed per diem rate:

(a) Pharmacy - After the first two hundred dollars per day in total allowed covered charges for any combination of pharmacy services that includes prescription drugs, total parenteral nutrition (TPN) therapy, IV infusion therapy, and/or epogen/neupogen therapy;

(b) Radiology services;

(c) Nuclear medicine services;

(d) Computerized tomographic (CT) scan;

(e) Operating room services;

(f) Anesthesia services;

(g) Blood storage and processing;

(h) Blood administration;

(i) Other imaging services - Ultrasound;

(j) Pulmonary function services;

(k) Cardiology services;

(l) Recovery room services;

(m) EKG/ECG services;

(n) Gastro-intestinal services;

(o) Inpatient hemodialysis; and

(p) Peripheral vascular laboratory services.

(2) The department uses the appropriate inpatient or outpatient payment method described in other published WAC to ((reimburse)) pay providers other than LTAC ((facilities)) hospitals for services and equipment that are covered by the department but not included in the LTAC fixed per diem rate. The provider must bill the department directly and the department ((reimburses)) pays the provider directly.

(3) Transportation services that are related to transporting a client to and from another facility for the provision of outpatient medical services while the client is still an inpatient at the LTAC ((facility)) hospital, or related to transporting a client to another facility after discharge from the LTAC ((facility)) hospital:

(a) Are not covered or reimbursed through the LTAC fixed per diem rate;

(b) Are not ((reimbursable)) payable directly to the LTAC ((facility)) hospital;

(c) Are subject to the provisions in chapter 388-546 WAC; and

(d) Must be billed directly to the:

(i) Department by the transportation company to be reimbursed if the client required ambulance transportation; or

(ii) Department's contracted transportation broker, subject to the prior authorization requirements and provisions described in chapter 388-546 WAC, if the client:

(A) Required ((nonemergent)) nonemergency transportation; or

(B) Did not have a medical condition that required transportation in a prone or supine position.

(4) The department evaluates requests for covered transportation services that are subject to limitations or other restrictions, and approves such services beyond those limitations or restrictions under the provisions of WAC 388-501-0165 and 388-501-0169.

(5) When the department established a special client service contract to complement the core provider agreement with an out-of-state LTAC hospital for services, the contract terms take precedence over any conflicting payment program policies set in WAC by the department.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, 388-550-2596, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090. 03-02-056, 388-550-2596, filed 12/26/02, effective 1/26/03; 02-14-162, 388-550-2596, filed 7/3/02, effective 8/3/02.]

Washington State Code Reviser's Office