WSR 08-17-102

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed August 20, 2008, 9:06 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 07-16-107.

Title of Rule and Other Identifying Information: The department is amending WAC 388-550-2570 LTAC program definitions, 388-550-2580 Requirements for becoming an LTAC hospital, and 388-550-2590 Department prior authorization requirements for Level 1 and Level 2 LTAC services.

Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6094), on September 23, 2008, at 10:00 a.m.

Date of Intended Adoption: Not sooner than September 24, 2008.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on September 23, 2008.

Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by September 16, 2008, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at johnsjl4@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: In chapter 388-550 WAC, Hospital services, the proposed rule updates and clarifies sections pertaining to the department's long-term acute care (LTAC) program definitions, requirements, and processes.

Reasons Supporting Proposal: Updating and clarifying the rules will result in better understanding and compliance by providers.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.

Statute Being Implemented: RCW 74.08.090 and 74.09.500.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of social and health services, governmental.

Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1342; Implementation and Enforcement: Bev Atteridge, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1575.

No small business economic impact statement has been prepared under chapter 19.85 RCW. Health and recovery services administration has analyzed the proposed rule and concluded that no new costs will be imposed on small businesses affected by them. The preparation of a comprehensive small business economic impact statement is not required under RCW 19.85.030.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Bev Atteridge, 626 8th Avenue S.E., Olympia, WA 98504-5506, phone (360) 725-1575, fax (360) 586-1471, e-mail atterbj@dshs.wa.gov.

August 14, 2008

Stephanie E. Schiller

Rules Coordinator

4015.2
AMENDATORY SECTION(Amending WSR 07-11-129, filed 5/22/07, effective 8/1/07)

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 long-term acute-care (LTAC) program.

"Level 1 services" means long-term acute-care (LTAC) services provided to a client((s)) who requires ((more than)) eight or more hours of direct skilled nursing care per day and the client's medical needs cannot be met at a lower level of care due to clinical complexity. 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)) Care for a client who has:

(a) Chronic open wounds that require on-site wound care specialty services and daily assessments and/or interventions; and

(b) At least one comorbid condition (such as chronic renal failure requiring hemodialysis).

"Level 2 services" means long-term acute-care (LTAC) services provided to a client((s)) who requires four ((to eight)) or more hours of direct skilled nursing care per day, and the clients' medical needs cannot be met at a lower level of care due to clinical complexity. Level 2 services include at least ((two)) one of the following:

(1) Ventilator care for a client((s)) who ((are stable, dependent on a)) is ventilator-dependent and is not weanable((,)) and ((have)) has complex medical needs; or

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

(a) Has a tracheostomy;

(b) Requires frequent respiratory therapy services for complex airway management and has the potential for decannulation; and

(c) Has at least one comorbid condition (such as quadriplegia).

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

"Long-term acute-care" means inpatient intensive long-term care services provided in department-approved LTAC 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 a department-approved transportation broker or a transportation company doing business with the department.))

[Statutory Authority: RCW 74.08.090, 74.09.500. 07-11-129, 388-550-2570, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2570, filed 7/3/02, effective 8/3/02.]

Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.
AMENDATORY SECTION(Amending WSR 07-11-129, filed 5/22/07, effective 8/1/07)

WAC 388-550-2580   Requirements for becoming an LTAC hospital.   (1) To apply to become a department-approved long-term acute-care (LTAC) hospital, the department requires a hospital to:

(a) Submit a letter of request to:

LTAC Program Manager

Division of Healthcare Services

Health and Recovery Services Administration

P.O. Box 45506

Olympia WA 98504-5506; and


(b) Include in the letter required under (a) of this subsection, documentation that confirms the ((facility)) hospital is:

(i) Medicare-certified for LTAC;

(ii) Accredited by the joint commission on accreditation of healthcare organizations (JCAHO);

(iii) ((For an in-state hospital)) Licensed as an acute care hospital by the department of health (DOH) under ((WAC 246-310-010)) chapter 246-320 WAC (if an in-state hospital), or by the state in which the hospital is located (if an out-of-state hospital); and

(iv) ((For a hospital located out-of-state, licensed as an acute care hospital by that state; and

(v) Contracted)) Enrolled with the department ((to provide LTAC services if the LTAC hospital is located outside the state of Washington)) as a Medicaid participating provider.

(2) ((The)) A hospital qualifies as a department-approved LTAC hospital when:

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

(b) The department's clinical staff has conducted an on-site visit and recommended approval of the hospital's request for LTAC designation; and

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

(3) Department-approved LTAC hospitals must meet the general requirements in chapter 388-502 WAC.

(4) The department may, in its sole discretion, approve a hospital located in Idaho or Oregon that is not in a designated bordering city as an LTAC hospital if:

(a) The hospital meets the requirements of this section; and

(b) The hospital provider signs a contract with the department agreeing to the payment rates established for LTAC services in accordance with WAC 388-550-2595.

(5) The department does not have any legal obligation to approve any hospital or other entity as an LTAC hospital.

[Statutory Authority: RCW 74.08.090, 74.09.500. 07-11-129, 388-550-2580, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2580, filed 7/3/02, effective 8/3/02.]


AMENDATORY SECTION(Amending WSR 07-11-129, filed 5/22/07, effective 8/1/07)

WAC 388-550-2590   Department prior authorization requirements for Level 1 and Level 2 LTAC services.   (1) The department requires prior authorization for Level 1 and Level 2 long-term acute-care (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; and

(B) ((Meet the high cost outlier or high outlier status, respectively, at the transferring hospital as described in WAC 388-550-3700. 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 hospital, submit a request for prior authorization to the ((the department's clinical consultation team)) department by fax, electronic mail, or telephone, as published in the department's LTAC billing instructions;

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

(C) ((Receive)) Obtain 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)) when accepting the client from the transferring hospital; and

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

(b) For any extension((s)) 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 criteria in (a) of this subsection must be met, and 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 department(('s clinical consultation team by fax, electronic mail, or telephone; and

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

(2) The department(('s clinical consultation team)) authorizes 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.

(3) 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, the department may request additional information from the client and the facility, or both. After the department reviews the available information, the result may be:

(a) A reversal of the initial department decision;

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

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

(((3))) (4) The department may authorize an administrative day rate payment for a client who meets one or more of the following. The client:

(a) Does not meet the requirements ((described in this section)) for Level 1 or Level 2 LTAC services;

(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, 74.09.500. 07-11-129, 388-550-2590, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. 02-14-162, 388-550-2590, filed 7/3/02, effective 8/3/02.]

Washington State Code Reviser's Office