Effective Date of Rule: October 1, 2011.

     Purpose: Pursuant to 2ESHB 1087, effective October 1, 2011, the health care authority (HCA) is directed to restrict coverage of emergency room visits to those involving emergency services.

     Citation of Existing Rules Affected by this Order: Amending WAC 182-550-1200.

     Statutory Authority for Adoption: Section 213, chapter 50, Laws of 2011 (2ESHB 1087), RCW 74.08.090, 43.88.290.

     Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal year 2009, 2010, 2011, 2012 or 2013, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.

     Reasons for this Finding: On June 15, 2011, the Washington state legislature filed 2ESHB 1087 which directs HCA to collaborate closely with the Washington state hospital and medical associations in identifying the diagnostic codes and retroactive review procedures that will be used to determine whether an emergency room visit is a nonemergency condition to assure that conditions that require emergency treatment continue to be covered.

     Delaying the adoption of this rule could jeopardize the state's ability to continue to provide healthcare coverage for clients with conditions that require emergency treatment.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.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 0, 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 1, Repealed 0.

     Date Adopted: September 28, 2011.

Kevin M. Sullivan

Rules Coordinator

OTS-4318.1

AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-550-1200   Restrictions on hospital coverage.   A hospital covered service provided to a client eligible under a medical assistance program that is paid by the ((department's)) agency's fee-for-service((s)) payment system must be within the scope of the client's medical assistance program. Coverage restriction includes, but is not limited to, the following:

     (1) Clients enrolled with the ((department's)) agency's managed care organization (MCO) plans are subject to the respective plan's policies and procedures for coverage of hospital services;

     (2) Clients covered by primary care case management are subject to the clients' primary care physicians' approval for hospital services;

     (3) For emergency care exemptions for clients described in subsections (1) and (2) of this section, see WAC ((388-538-100)) 182-538-100.

     (4) Coverage of emergency room visits that do not meet the definition of emergency services according to WAC 182-550-1050.

     (a) The agency covers a maximum of three emergency room visits that do not meet the definition of emergency services per client, per state fiscal year (for 2012 only, the agency defines the state fiscal year as October 1, 2011, through June 30, 2012) with the following exceptions:

     (i) A client who is either:

     (A) In foster care; or

     (B) On the alien emergency medical (AEM) program (see WAC 388-438-0120).

     (ii) A client who lives in one of the following settings:

     (A) A department of social and health services-licensed residential setting/home;

     (B) A skilled nursing facility;

     (C) An institution for the mentally diseased; or

     (D) A chemical dependency treatment facility.

     (iii) The visit results in either:

     (A) A surgery that requires the use of the hospital's operating room; or

     (B) An extended, payable clinical observation stay.

     (iv) A primary diagnosis that is:

     (A) Psychiatric; or

     (B) Drug and alcohol detoxification.

     (v) A visit:

     (A) Where signs and/or symptoms of abuse are present and documented;

     (B) For a client that requires medical clearance by a designated mental health professional required for placement in a psychiatric facility;

     (C) That results in an inpatient admission;

     (D) That results in a transfer to another hospital;

     (E) For a client that is brought to the hospital via:

     (I) Ambulance;

     (II) Emergency medical transport; or

     (III) Police transport for a client that has not been booked and retained in jail.

     (F) For a client who is transferred from another hospital, urgent care center, or ambulatory surgical center; or

     (G) That meets the agency's published expedited authorization criteria for emergency visits.

     (b) An expedited authorization number is required to indicate to the agency the visit is excluded because the conditions in (a)(ii) and (v)(B), (E), and (F) of this subsection are met.

     (c) Emergency room visits in excess of three visits per state fiscal year as described in (a) of this subsection are noncovered.

     (d) Providers of noncovered emergency room visits and related services must comply with WAC 182-502-0160, Billing a client, when billing the client. All services associated with the noncovered visit are considered part of the visit. This includes, but is not limited to: Hospital, professional, diagnostic, and laboratory fees for services that may occur either within or outside of the hospital system.

     (e) The agency will retroactively recoup payments from all of the billing providers. This includes, but is not limited to: Hospital, professional, diagnostic, and laboratory fees for services that may occur either within or outside of the hospital system.

     (5) Coverage for psychiatric indigent inpatient (PII) clients is limited to voluntary inpatient psychiatric hospital services, subject to the conditions and limitations of WAC 388-865-0217 and this chapter:

     (a) Out-of-state healthcare is not covered for clients under the PII program; and

     (b) Bordering city hospitals and critical border hospitals are not considered ((instate)) in-state hospitals for PII program claims.

     (((5))) (6) Healthcare services provided by a hospital located out-of-state are:

     (a) Not covered for clients eligible under the medical care services (MCS) program. However, clients eligible for MCS are covered for that program's scope of care in bordering city and critical border hospitals.

     (b) Covered for:

     (i) Emergency care for eligible medicaid and state children's health insurance program (SCHIP) clients without prior authorization, based on the medical necessity and utilization review standards and limits established by the ((department)) agency.

     (ii) Nonemergency out-of-state care for medicaid and SCHIP clients when prior authorized by the ((department)) agency or agency's designee based on the medical necessity and utilization review standards and limits.

     (iii) Hospitals in bordering cities and critical border hospitals, based on the same client eligibility criteria and authorization policies as for ((instate)) in-state hospitals. See WAC ((388-501-0175)) 182-501-0175 for a list of bordering cities.

     (c) Covered for out-of-state voluntary inpatient psychiatric hospital services for eligible medicaid and SCHIP clients based on authorization by a ((mental health)) division (((MHD))) of behavioral health and recovery (DBHR) designee.

     (((6))) (7) See WAC ((388-550-1100)) 182-550-1100 for hospital services for chemical-using pregnant (CUP) women.

     (((7))) (8) All psychiatric inpatient hospital admissions, length of stay extensions, and transfers must be prior authorized by a ((MHD)) DBHR designee. See WAC ((388-550-2600)) 182-550-2600.

     (((8))) (9) For clients eligible for both medicare and medicaid (dual eligibles), the ((department)) agency pays deductibles and coinsurance, unless the client has exhausted his or her medicare Part A benefits. If medicare benefits are exhausted, the department pays for hospitalization for such clients subject to ((department)) agency rules. See also chapter ((388-502)) 182-502 WAC.

     (((9))) (10) The ((department)) agency does not pay for covered inpatient hospital services for a medical assistance client:

     (a) Who is discharged from a hospital by a physician because the client no longer meets medical necessity for acute inpatient level of care; and

     (b) Who chooses to stay in the hospital beyond the period of medical necessity.

     (((10))) (11) If the hospital's utilization review committee determines the client's stay is beyond the period of medical necessity, as described in subsection (((9))) (10) of this section, the hospital must:

     (a) Inform the client in a written notice that the ((department)) agency is not responsible for payment (42 CFR 456);

     (b) Comply with the requirements in WAC ((388-502-0160)) 182-502-0160 in order to bill the client for the service(s); and

     (c) Send a copy of the written notice in (a) of this subsection to the ((department)) agency or agency designee.

     (((11))) (12) Other coverage restrictions, as determined by the ((department)) agency.

[11-14-075, recodified as § 182-550-1200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. 07-14-018, § 388-550-1200, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652. 99-06-046, § 388-550-1200, filed 2/26/99, effective 3/29/99. 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, § 388-550-1200, filed 12/18/97, effective 1/18/98.]

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