WSR 12-11-076

PROPOSED RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed May 16, 2012, 3:00 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 12-07-074.

Title of Rule and Other Identifying Information: WAC 182-531-2000 Increased payments for physician-related services for qualified trauma cases and 182-550-5450 Supplemental distributions to approved trauma service centers.

Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://maa.dshs.wa.gov/pdf/CherryStreetDirectionsNMap.pdf

or directions can be obtained by calling (360) 725-1000), on June 26, 2012, at 10:00 a.m.

Date of Intended Adoption: Not sooner than June 27, 2012.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on June 26, 2012.

Assistance for Persons with Disabilities: Contact Kelly Richters by June 18, 2012, TTY/TDD (800) 848-5429 or (360) 725-1307 or e-mail kelly.richters@hca.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: On July 1, 2012, a substantial number (100,000+) of fee-for-service (FFS) clients will be shifted to managed care. HCA currently makes supplemental payments to trauma care providers for FFS clients who meet specified criteria, but trauma care services provided to managed care clients are not eligible for such payments. The proposed rules/amendments will allow HCA to make supplemental payments to trauma care providers for clients in managed care. HCA will also apply for a federal waiver to pay hospitals the supplemental payments outside the capitation rate. These steps will help prevent the loss of up to $7.5M per year in federal matching funds from the statewide trauma care system. The proposed rules also include housekeeping changes (e.g., replacing "DSHS" with "HCA").

Reasons Supporting Proposal: See Purpose statement above.

Statutory Authority for Adoption: RCW 41.05.021.

Statute Being Implemented: RCW 41.05.021.

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

Name of Proponent: HCA, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Ayuni Wimpee, P.O. Box 45510, Olympia, WA 98504-5510, (360) 725-1835.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has analyzed the proposed rule and concludes that it does not impose more than minor costs for affected small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules [review] committee or applied voluntarily.

May 16, 2012

Kevin M. Sullivan

Rules Coordinator

OTS-4767.1


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

WAC 182-531-2000   Increased payments for physician-related services for qualified trauma cases.   (1) The ((department of social and health services' (DSHS))) health care authority's physician trauma care fund (TCF) is an amount that is legislatively appropriated to ((DSHS)) the medicaid agency each biennium for the purpose of increasing the ((department's)) agency's payment to physicians and other clinicians (those who are performing services within their licensed and credentialed scope of practice) providing qualified trauma care services to medical assistance clients covered under the ((department's fee-for-service)) agency's medical assistance programs.

(2) Trauma care services provided to clients in:

(a) ((Fee-for-service clients in medicaid, general assistance-unemployable (GAU), Alcohol and Drug Addiction Treatment and Support Act (ADATSA))) Medicaid, disability lifeline (DL), incapacity-based medical care services (MCS), children's health insurance program (CHIP), and apple health for kids, qualify for enhanced rate payments from the TCF. Trauma care services provided to a ((GAU)) DL or ((ADATSA)) MCS client qualify for enhanced rates only during the client's certification period. See WAC ((388-416-0010)) 182-504-0010;

(b) ((Clients in)) The alien emergency medical (AEM), refugee assistance, and alien medical programs do not qualify for enhanced rate payments from the TCF; and

(c) ((Clients enrolled in the department's)) The agency's managed care programs ((do not)) qualify for enhanced rate payments from the TCF, effective with dates of service on and after July 1, 2012.

(3) To receive payments from the TCF, a physician or other clinician must:

(a) Be on the designated trauma services response team of any department of health (DOH)-designated or DOH-recognized trauma service center;

(b) Meet the provider requirements in this section and other applicable ((WAC)) rules;

(c) Meet the billing requirements in this section and other applicable ((WAC)) rules; and

(d) Submit all information the ((department)) agency requires to monitor the trauma program.

(4) Except as described in subsection (5) of this section and subject to the limitations listed, the ((department)) agency makes payments from the TCF to physicians and other clinicians:

(a) For only those trauma services that are designated by the ((department)) agency as "qualified." Qualified trauma care services include:

(i) Follow-up surgical services provided within six months of the date of the injury. These surgical procedures must have been planned during the initial acute episode of injury; and

(ii) Physiatrist services provided during an inpatient stay immediately following, and within six months of, the ((initial episode of)) qualifying traumatic injury.

(b) For hospital-based professional services-only, and for follow-up surgeries performed in a medicare-certified ambulatory surgery center (ASC). The follow-up surgery must have been performed within six months of the initial traumatic injury.

(c) Only for trauma cases that meet the injury severity score (ISS) (a summary rating system for traumatic anatomic injuries) ((of)) criteria specified by the agency. The current qualifying ISS are:

(i) Thirteen or greater for an adult trauma patient (a client age fifteen or older); ((or)) and

(ii) Nine or greater for a pediatric trauma patient (a client younger than age fifteen).

(d) On a per-client basis in any DOH-designated or DOH-recognized trauma service center.

(e) At a rate of two and one-half times the ((department's)) agency's current fee-for-service rate for qualified trauma services, or other payment enhancement percentage the ((department determines as)) agency deems appropriate.

(i) The ((department)) agency monitors the payments from the TCF during each state fiscal year (SFY) and makes necessary adjustments to the rate to ensure that total payments from the TCF for the ((biennium)) SFY will not exceed the legislative appropriation for that ((biennium)) SFY.

(ii) Laboratory and pathology charges are not eligible for payments from the TCF. (See subsection (6)(b) of this section.)

(5) When a trauma case is transferred from one hospital to another, the ((department)) agency makes payments from the TCF to physicians and clinicians, according to the ISS score as follows:

(a) If the transferred case meets or exceeds the appropriate ISS threshold described in subsection (4)(c) of this section, providers who furnish qualified trauma services, whether in ((either)) the transferring or receiving facility, are eligible for payments from the TCF.

(b) If the transferred case is below the ISS threshold described in subsection (4)(c) of this section, only providers who furnish qualified trauma services in the receiving hospital are eligible for payments from the TCF.

(6) The ((department)) agency makes a TCF payment to a physician or clinician:

(a) Only when the provider submits an eligible trauma claim with the appropriate trauma indicator within the time frames specified by the ((department)) agency; and

(b) On a per-claim basis. Each qualifying trauma service and/or procedure on the provider's claim is paid at the ((department's)) agency's current fee-for-service rate, multiplied by the appropriate payment enhancement percentage described in subsection (4)(e) of this section. Laboratory and pathology services and/or procedures are not eligible for payments from the TCF and are paid at the ((department's)) agency's current fee-for-service rate.

(7) For purposes of the payments from the TCF to physicians and other clinicians, all of the following apply:

(a) The ((department)) agency considers a request for a claim adjustment submitted by a provider only if the ((department)) agency receives the adjustment request within three hundred sixty-five days from the date of the initial trauma service. At its discretion, and with sufficient public notice, the ((department)) agency may adjust the deadline for submission and/or adjustment of trauma claims in response to budgetary or other program needs;

(b) Except as provided in subsection (7)(a) of this section, the deadline for making adjustments to a trauma claim is the same as the deadline for submitting the initial claim to the ((department)) agency as specified in WAC ((388-502-0150(3))) 182-502-0150(3). See WAC ((388-502-0150)) 182-502-0150 (11) and (12) for other time limits applicable to trauma claims;

(c) All claims and claim adjustments are subject to federal and state audit and review requirements; and

(d) The total payments from the TCF disbursed to providers by the ((department)) agency in ((a biennium)) an SFY cannot exceed the amount appropriated by the legislature for that ((biennium)) SFY. The ((department)) agency has the authority to take whatever actions are needed to ensure the ((department)) agency stays within its TCF appropriation (see subsection (4)(e)(i) of this section).

[11-14-075, recodified as 182-531-2000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 70.168.040, 74.08.090, and 74.09.500. 10-12-013, 388-531-2000, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.500, and chapter 43.20A RCW. 08-18-029, 388-531-2000, filed 8/27/08, effective 9/27/08. Statutory Authority: RCW 74.08.090, 74.09.500. 05-20-050, 388-531-2000, filed 9/30/05, effective 10/31/05; 04-19-113, 388-531-2000, filed 9/21/04, effective 10/22/04.]

OTS-4768.1


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

WAC 182-550-5450   Supplemental distributions to approved trauma service centers.   (1) The trauma care fund (TCF) is an amount ((legislatively)) appropriated to the ((department)) medicaid agency each ((biennium)) state fiscal year (SFY), at the legislature's sole discretion, for the purpose of supplementing the ((department's)) agency's payments to eligible trauma service centers for providing qualified trauma services to medicaid ((fee-for-service)) clients. Claims for trauma care provided to medicaid clients enrolled in the ((department's)) agency's managed care programs are ((not)) eligible for supplemental distributions from the TCF effective with dates of service on and after July 1, 2012.

(2) The ((department)) agency makes supplemental distributions from the TCF to qualified hospitals, subject to the provisions in this section and subject to legislative action.

(3) To qualify for supplemental distributions from the TCF, a hospital must:

(a) Be designated or recognized by the department of health (DOH) as an approved Level I, Level II, or Level III adult or pediatric trauma service center;

(b) Meet the provider requirements in this section and other applicable ((WAC)) rules;

(c) Meet the billing requirements in this section and other applicable ((WAC)) rules;

(d) Submit all information the ((department)) agency requires to monitor the program; and

(e) Comply with DOH's Trauma Registry reporting requirements.

(4) Supplemental distributions from the TCF are:

(a) Allocated into five payment pools. Timing of payments is described in subsection (5) of this section. Distributions from the payment pools to the individual hospitals are determined by first summing the agency's qualifying payments to each eligible ((hospital's qualifying payments)) hospital since the beginning of the service year and expressing this amount as a percentage of the agency's total payments to all eligible hospitals for qualifying services provided during the service year-to-date. For TCF purposes, service year is defined as the ((state fiscal year)) SFY. Each hospital's qualifying payment percentage for the service year-to-date is multiplied by the available amount for the service year-to-date, and then the ((department)) agency subtracts what has been allocated to each hospital for the service year-to-date to determine the portion of the current payment pool to be paid to each qualifying hospital. ((This method for determining supplemental distributions to hospitals applies to TCF allotments beginning with state fiscal year (SFY) 2008.)) Eligible hospitals and qualifying payments are described in (a)(i) through (iii) of this subsection. Qualifying payments are the agency's payments to:

(i) ((Qualifying payments are the department's payments to)) Level I, Level II, and Level III trauma service centers for qualified medicaid trauma cases since the beginning of the service year. The ((department)) agency determines the countable payment for trauma care provided to medicaid clients based on date of service, not date of payment;

(ii) The ((department's payments to)) Level I, Level II, and Level III hospitals for trauma cases transferred ((in)) to these facilities since the beginning of the service year. A Level I, Level II, or Level III hospital that receives a transferred trauma case from any lower level hospital is eligible for the enhanced payment, regardless of the client's injury severity score (ISS); and

(iii) ((The department's payments to)) Level II and Level III hospitals for qualified trauma cases (those that meet or exceed the ISS criteria in ((subsection (4)))(b) of this ((section)) subsection) transferred by these hospitals since the beginning of the service year to a trauma service center with a higher designation level.

(b) Paid only for a medicaid trauma case that meets:

(i) The ISS of thirteen or greater for an adult trauma patient (a client age fifteen or older);

(ii) The ISS of nine or greater for a pediatric trauma patient (a client younger than age fifteen); or

(iii) The conditions of ((subsection (4)))(c) of this subsection.

(c) Made to hospitals, as follows, for a trauma case that is transferred:

(i) A hospital that receives the transferred trauma case qualifies for payment regardless of the ISS if the hospital is designated or recognized by DOH as an approved Level I, Level II, or Level III adult or pediatric trauma service center;

(ii) A hospital that transfers the trauma case qualifies for payment only if:

(A) It is designated or recognized by DOH as an approved Level II or Level III adult or pediatric trauma service center; and

(B) The ISS requirements in (b)(i) or (((b)))(ii) of this subsection are met.

(iii) A hospital that DOH designates or recognizes as an approved Level IV or Level V trauma service center does not qualify for supplemental distributions for trauma cases that are transferred in or transferred out, even when the transferred cases meet the ISS criteria in ((subsection (4)))(b) of this ((section)) subsection.

(d) Not funded by disproportionate share hospital (DSH) funds; and

(e) Not distributed by the ((department)) agency to:

(i) Trauma service centers designated or recognized as Level IV or Level V;

(ii) Critical access hospitals (CAHs), except when the CAH is also a Level III trauma service center((. Beginning with qualifying trauma services provided in SFY 2007, the department allows a hospital with this dual status to receive distributions from the TCF)); or

(iii) Any facility for follow-up services related to the qualifying trauma incident but provided to the client after the client has been discharged from the initial hospitalization for the qualifying injury.

(5) Distributions for an SFY are paid as follows:

(a) The first supplemental distribution from the TCF is made three to six months after the SFY begins;

(b) Subsequent distributions are made approximately every two to four months after the first distribution is made, except as described in ((subsection)) (c) of this subsection;

(c) The final distribution from the TCF for ((the same)) an SFY is:

(i) Made one year after the end of the SFY;

(ii) ((Based on the SFY that the TCF designated amount relates to;)) Limited to the remaining balance of the agency's TCF appropriation for that SFY; and

(iii) Distributed based on each eligible hospital's percentage share of the total payments made by the ((department)) agency to all designated trauma service centers for qualified trauma ((cases)) services provided during the relevant SFY.

(6) For purposes of the supplemental distributions from the TCF, all of the following apply:

(a) The ((department)) agency considers a provider's request for a trauma claim adjustment only if the adjustment request is received by the ((department)) agency within three hundred sixty-five calendar days from the date of the initial trauma service. At its discretion, and with sufficient public notice, the ((department)) agency may adjust the deadline for submission and/or adjustment of trauma claims in response to budgetary program needs;

(b) Except as provided in ((subsection (6)))(a) of this ((section)) subsection, the deadline for making adjustments to a trauma claim is the same as the deadline for submitting the initial claim to the ((department)) agency as specified in WAC ((388-502-0150(3))) 182-502-0150(3). See WAC ((388-502-0150)) 182-502-0150 (11) and (12) for other time limits applicable to TCF claims;

(c) All claims and claim adjustments are subject to federal and state audit and review requirements; and

(d) The total amount of supplemental distributions from the TCF disbursed to eligible hospitals by the ((department)) agency in any ((biennium)) SFY cannot exceed the amount appropriated by the legislature for that ((biennium)) SFY. The ((department)) agency has the authority to take whatever actions necessary to ensure the department stays within the TCF appropriation.

[11-14-075, recodified as 182-550-5450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 70.168.040, 74.08.090, and 74.09.500. 10-12-013, 388-550-5450, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.160, 74.09.500, and 70.168.040. 08-08-065, 388-550-5450, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090, 74.09.500. 07-14-090, 388-550-5450, filed 6/29/07, effective 8/1/07; 06-08-046, 388-550-5450, filed 3/30/06, effective 4/30/06; 04-19-113, 388-550-5450, filed 9/21/04, effective 10/22/04.]

Washington State Code Reviser's Office