WSR 09-08-117



(Health and Recovery Services Administration)

[ Filed March 31, 2009, 5:24 p.m. ]

     Original Notice.

     Preproposal statement of inquiry was filed as WSR 09-04-072.

     Title of Rule and Other Identifying Information: The department is amending WAC 388-502-0150 Time limits for providers to bill MAA, 388-550-2800 Payment methods and limits -- Inpatient hospital services for medicaid and state children's health insurance program (SCHIP) clients, 388-550-3000 Payment method -- Diagnosis related groups (DRG), 388-550-3010 Payment method -- Per diem payment, 388-550-3020 Payment method -- Bariatric surgery -- Per case payment, 388-550-3460 Payment method -- Per diem rate, 388-550-3900 Payment method -- Bordering city hospitals and critical border hospitals, and 388-550-4000 Payment method -- Emergency services -- Out-of-state hospitals.

     Hearing Location(s): Office Building 2, Auditorium, DSHS Headquarters, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at or by calling (360) 664-6094), on May 26, 2009, at 10:00 a.m.

     Date of Intended Adoption: Not sooner than May 27, 2009.

     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, fax (360) 664-6185, by 5 p.m. on May 26, 2009.

     Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by May 12, 2009, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed changes update and clarify hospital-related and provider-related sections and are intended to address the anticipated levels of funding from the legislature, inform providers of program changes, and clarify and update current language. These rules:

Add language putting providers on notice that the department will make adjustments to existing inpatient hospital rates and/or payment methods, by applying an "inpatient adjustment factor," when directed by the legislature to achieve targeted budget expenditure levels;
Add language regarding the department's intent to apply the inpatient adjustment factor in a proportional manner across the inpatient hospital rates and payment methods;
Add language that makes a delivery by cesarean section without complications and comorbidities payable at the same rate as a vaginal birth with complicated diagnosis;
Expand the types of facilities and/or programs to which an acute care hospital or distinct unit can transfer an eligible client and receive a prorated diagnosis related group (DRG) payment from the department;
Add clarifying language that the department uses the per diem payment method to pay for hospital stays that have insufficient data available to determine stable relative weights and for other specified specialty services;
Add language that the department may adjust the DRG conversion factor when directed by the legislature to achieve budgetary targets;
Add language that the department may adjust the per diem rate when directed by the legislature to achieve budgetary targets;
Add language that the department may adjust a per case payment when directed by the legislature to achieve budgetary targets;
Put in rule how per diem rates are determined for chronic pain services;
Remove "emergency services" from the title of WAC 388-550-4000 and clarify that the section applies to both emergency and nonemergency services provided by out-of-state hospitals;
Add language that the department may adjust the outlier threshold or the percentages of outlier adjustment factors when directed by the legislature to achieve budgetary targets;
Reduce the total period allowed for resubmission or modification of a claim, other than a prescription drug or major trauma claim, from thirty-six months to twenty-four months from the date of service, effective with dates of services or admission on and after July 1, 2009;
Add language specifying a three-hundred sixty-five-day limit for resubmission or modification of a claim for major trauma services, consistent with the limit set in WAC 388-550-5450 and 388-531-2000; and
Update, clarify, and rearrange current language for improved readability.

     Reasons Supporting Proposal: The department must meet the legislature's targeted budget expenditure levels for payment of hospital and hospital-related services provided to medical assistance clients.

     Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530.

     Statute Being Implemented: RCW 74.04.050, 74.04.057, 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 45505, Olympia WA 98504-5504, (360) 725-1342; Implementation and Enforcement: Carolyn Adams, P.O. Box 45510, Olympia, WA 98504-5510, (360) 725-1854.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. These rules do not impact small businesses.

     A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Carolyn Adams, Health and Recovery Services Administration, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1854, fax (360) 753-9152, e-mail

March 30, 2009

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 09-09 issue of the Register.

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