WSR 07-14-018

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed June 22, 2007, 2:32 p.m. , effective August 1, 2007 ]


Effective Date of Rule: August 1, 2007.

Purpose: The department is updating and clarifying sections in chapter 388-550 WAC relating to (1) hospital requirements for transplants and bariatric surgery; (2) inpatient chronic pain management and hospice services; (3) payment methods for Medicaid and SCHIP clients; (4) covered and noncovered outpatient services; (5) restrictions on hospital coverage; (6) revenue code categories and subcategories for outpatient and inpatient hospital services for dates of admission before August 1, 2007, and on and after August 1, 2007; (7) specific noncovered services; (8) authorization and utilization review of hospital services; (9) specialty services not requiring prior authorization; and (10) transplant coverage. In addition, the department is changing verbiage from "medical assistance administration (MAA)" to "the department," and "facility" to "hospital."

Citation of Existing Rules Affected by this Order: Amending WAC 388-550-1200, 388-550-1300, 388-550-1350, 388-550-1400, 388-550-1500, 388-550-1600, 388-550-1700, 388-550-1800, 388-550-1900, 388-550-2100, 388-550-2200, 388-550-2301, 388-550-2500, and 388-550-2800.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.500.

Adopted under notice filed as WSR 07-10-104, 07-10-105, 07-10-106 on May 1, 2007.

Changes Other than Editing from Proposed to Adopted Version: WAC 388-550-2800(1) (Table) Third column in table under "Process to adjust for third-party liability insurance and any other client responsibility":

Lesser of either the DRG billed amount minus the third-party payment amount and any client responsibility amount, or the allowable, allowed amount, minus the third-party payment amount and any client responsibility amount.

The allowable minus the third-party payment amount and any client responsibility amount. (No change.)

For the "hold harmless" settlement, the lesser of The the billed amount minus the third-party payment amount and any client responsibility amount, or the allowable allowed amount minus the third-party payment amount and any client responsibility amount. The payment made is the federal share only.

Lesser of either the billed amount minus the third-party payment amount and any client responsibility amount, or the Ssingle case rate allowed amount minus the third-party payment amount and any client responsibility amount.

Lesser of either the billed amount minus the third-party payment amount and any client responsibility amount, or the Pper diem allowed amount minus the third-party payment amount and any client responsibility amount.

Per diem allowed amount, and for some services...

The allowable allowed amount, subject to retrospective cost settlement...

Paid according to applicable...(No change.)

WAC 388-550-2900(1) (After table.) See WAC 388-550-4800 for payment methods used by the department for inpatient hospital services provided to clients eligible under state-administered programs. The department's policy for payment on state-administered program claims that involve third party liability (TPL) and/or client responsibility payments on claims is the same policy indicated in the table in subsection (1) in this section. However, to determine the department's payment on the claim, state-administered program rates, not medicaid or SCHIP rates, apply when comparing the lesser of either the billed amount minus the third-party payment and any client responsibility amount, or the allowed amount minus the third-party payment amount and any client responsibility amount.

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 15, 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 15, Repealed 0.

Date Adopted: June 21, 2007.

Stephanie E. Schiller

Rules Coordinator

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 07-16 issue of the Register.

Washington State Code Reviser's Office