WSR 13-14-052

PERMANENT RULES

HEALTH CARE AUTHORITY

(Medicaid Program)

[Filed June 27, 2013, 4:05 p.m., effective July 28, 2013]

Effective Date of Rule: Thirty-one days after filing.

Purpose: Clarify payment criteria for Medicare Part B deductible and coinsurance amounts and eliminate reference to Medicare Part D copay.

Citation of Existing Rules Affected by this Order: Amending WAC 182-530-7700.

Statutory Authority for Adoption: RCW 41.05.021, chapter 5, Laws of 2011 (ESHB 1086, 2010 2nd sp.s. c 1 s 208 (25)); and Section 1902 (n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.

Adopted under notice filed as WSR 13-11-148 on May 22, 2013.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: June 27, 2013.

Kevin M. Sullivan

Rules Coordinator

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

WAC 182-530-7700 Reimbursement—Dual eligible clients/medicare.

For clients who are dually eligible for medical assistance and medicare benefits, the following applies:

(1) Medicare Part B, the ((department)) agency pays providers for:

(a) An amount up to the ((department's)) agency's maximum allowable fee for drugs medicare does not cover, but the ((department)) agency covers; or

(b) Deductible and/or coinsurance amounts up to medicare's or the ((department's)) agency's maximum allowable fee, whichever is less, for drugs medicare and the ((department)) agency cover((; or

(c) Deductible and/or coinsurance amounts for clients under the qualified medicare beneficiary (QMB) program for drugs medicare covers but the department does not cover)).

(2) Medicare Part D:

(a) ((For payment of medicare Part D drugs:

(i))) Medicare is the ((primary)) payer for drugs covered under the medicare Part D ((drugs;

(ii))) benefit.

(b) The ((department)) agency does not pay((s only the copayment up to a maximum amount set by the Centers for Medicare and Medicaid Services (CMS); and

(iii) The client is responsible for copayments above the maximum amount)) for Part D drugs or Part D copayments.

(((b))) (c) For drugs excluded from the basic medicare Part D benefit((s)):

(i) The ((department)) agency offers the same drug benefit as a nondual eligible client has within those same classes;

(ii) If the client has another third party insurer, that insurer is the primary payer; and

(iii) The ((department)) agency is the payer of last resort.