PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 11-05-082.
Title of Rule and Other Identifying Information: WAC 388-501-0180 Healthcare services provided outside the state of Washington -- General provisions and 388-501-0184 Healthcare services provided outside of the United States and U.S. territories or in a foreign country.
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 http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html or by calling (360) 664-6094), on June 21, 2011, at 10:00 a.m.
Date of Intended Adoption: Not sooner than June 22, 2011.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 1115 Washington Street S.E., Olympia, WA 98504, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on June 21, 2011.
Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by June 7, 2011, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at jennisha.johnson@dshs.wa.gov.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules:
| • | Amend WAC to comply with Section 6505 of the Patient Protection and Affordable Care Act of 2010, which prohibits state medicaid agencies from making payments to institutions or entities located outside of the United States for healthcare services furnished to medical assistance clients out-of-country. Clarify that payment to providers who have furnished such services may be made to financial institutions or entities located within the United States. |
| • | Correct subsections (3) and (4) of WAC 388-501-0184 to read as follows: "For those medical assistance clients identified in subsection (2) of this section, ..." |
Reasons Supporting Proposal: Inform providers and other stakeholders of the change(s) in federal law. These policy changes are final. The department has to implement them or risk loss of federal matching funds. Implementation requires the department to submit a state plan amendment (SPA) and make necessary changes to WAC.
Statutory Authority for Adoption: RCW 74.04.057, 74.08.090, and 74.09.510.
Statute Being Implemented: RCW 74.08.090.
Rule is necessary because of federal law, Section 6505 of the Patient Protection and Affordable Care Act of 2010.
Name of Proponent: Department of social and health services, medicaid purchasing administration, governmental.
Name of Agency Personnel Responsible for Drafting: Jason R. P. Crabbe, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1346; 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. This is just a "housekeeping" change to correct errant WAC citations.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Carolyn Adams, Special Assistant for Healthcare Reform Implementation, Department of Social and Health Services, Division of Rates and Finance, P.O. Box 45510, Olympia, WA 98504, e-mail Carolyn.Adams@dshs.wa.gov.
May 13, 2011
Katherine I. Vasquez
Rules Coordinator
4300.1(1) Subject to the exceptions and limitations in this section, WAC 388-501-0182 and 388-501-0184, the department covers emergency and nonemergency out-of-state healthcare services provided to eligible Washington state medical assistance clients when the services are:
(a) Within the scope of the client's healthcare program as specified under chapter 388-501 WAC;
(b) Allowed to be provided outside the state of Washington by specific program WAC; and
(c) Medically necessary as defined in WAC 388-500-0005.
(2) The department does not cover services provided outside the state of Washington under the Involuntary Treatment Act (chapter 71.05 RCW and chapter 388-865 WAC), including designated bordering cities.
(3) When the department pays for covered healthcare
services furnished to an eligible Washington state medical
assistance client outside the state of Washington, its payment
is payment in full according to 42 CFR 447.15. ((The
department does not pay when the provider refuses to accept
the department's payment as payment in full.))
(4) The department determines coverage for transportation services provided out of state, including ambulance services, according to chapter 388-546 WAC.
(5) With the exception of designated bordering cities (see WAC 388-501-0175), if the client travels out of state expressly to obtain healthcare, the service(s) must be prior authorized by the department. See WAC 388-501-0182 for requirements related to out-of-state nonemergency treatment and WAC 388-501-0165 for the department's medical necessity determination process.
(6) The department does not cover healthcare services provided outside the United States and U.S. territories, with the exception of British Columbia, Canada. See WAC 388-501-0184 for limitations on coverage of, and payment for, healthcare provided to medical assistance clients in British Columbia, Canada.
(7) See WAC 388-502-0120 for provider requirements for payment of healthcare provided outside the state of Washington.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. 08-08-064, § 388-501-0180, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0180, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.035. 01-01-011, § 388-501-0180, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-501-0180, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-82-135 and 388-92-015.]
(1) The provisions of WAC 388-501-0182 apply to this section.
(2) The department does not pay for healthcare services furnished in a foreign country, except for medical services furnished in the province of British Columbia, Canada, under the conditions specified in this section. The department pays for medical services furnished in British Columbia, Canada to the following Washington state medical assistance clients only:
(a) Those who reside in Point Roberts, Washington;
(b) Those who reside in Washington communities along the border with British Columbia, Canada (see subsection (3) of this section for further clarification); and
(c) Members of the Canadian First Nations who live in Washington state.
(3) For those medical assistance clients identified in
subsection (((1))) (2) of this section, the department covers
emergency and nonemergency medical services provided in
British Columbia, Canada, when the services are:
(a) Within the scope of the client's healthcare program as specified in chapter 388-501 WAC;
(b) Allowed to be provided outside the United States and U.S. territories by specific program WAC; and
(c) Medically necessary as defined in WAC 388-500-0005.
(4) For those medical assistance clients identified in
subsection (((1))) (2) of this section, the department covers
nonemergency medical services in British Columbia, Canada,
only when:
(a) It is general practice for Washington state medical assistance clients residing in these particular localities to use medically necessary resources across the Canadian border; or
(b) The medical services in British Columbia, Canada are closer or more readily accessible to the client's Washington state residence. As applied to nonemergency medical services, the phrase "closer or more readily accessible to the client's Washington state residence" means:
(i) There is not a United States provider for the same service within twenty-five miles of the client's Washington state residence; and
(ii) The closest Canadian provider of service is closer than the closest U.S. provider of the service.
(5) The department does not cover services provided
((outside of the United States)) in British Columbia, Canada
under the Involuntary Treatment Act (chapter 71.05 RCW and
chapter 388-865 WAC).
(6) When the department pays for covered medical services
furnished to a Washington state medical assistance client in
British Columbia, Canada, its payment is payment in full
according to 42 CFR 447.15. ((The department does not pay
when the provider refuses to accept the department's payment
as payment in full.))
(7) A British Columbia, Canada provider who furnished healthcare services and/or covered items to a medical assistance client will receive payment from the department only when:
(a) Such reimbursement is made to a financial institution or entity located within the United States in U.S. dollars; and
(b) The participating British Columbia, Canada provider:
(i) Has signed a core provider agreement with the department;
(ii) Satisfies all medicaid conditions of participation;
(iii) Meets functionally equivalent licensing requirements; and
(iv) Complies with the same utilization control standards as in-state providers.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. 08-08-064, § 388-501-0184, filed 3/31/08, effective 5/1/08.]