WSR 14-16-019 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed July 24, 2014, 5:01 p.m., effective August 24, 2014] Effective Date of Rule: Thirty-one days after filing.
Purpose: Medicaid Expansion WACs - Phase 5. The health care authority (HCA) is implementing new regulations under the federal Patient Protection and Affordable Care Act in preparation for healthcare reform in Washington state. This includes the establishment of standalone rules for medical assistance programs, which are required under 2E2SHB 1738, Laws of 2011, which creates HCA as the single state agency responsible for the administrations and supervision of Washington apple health (medicaid program).
Citation of Existing Rules Affected by this Order: Repealing WAC 182-503-0532, 182-503-0555, 182-503-0560, 182-504-0030, 182-504-0040, 182-504-0100, 182-506-0020, 182-508-0010, 182-508-0015, 182-508-0020, 182-508-0030, 182-508-0035, 182-508-0040, 182-508-0050, 182-508-0060, 182-508-0070, 182-508-0080, 182-508-0090, 182-508-0100, 182-508-0110, 182-508-0120, 182-508-0130, 182-508-0160, 182-508-0220, 182-508-0230, 182-508-0300, 182-508-0305, 182-508-0310, 182-508-0315, 182-508-0320, 182-508-0325, 182-508-0330, 182-508-0335, 182-508-0340, 182-508-0345, 182-508-0350, 182-508-0355, 182-508-0360, 182-508-0365, 182-508-0370, 182-508-0375, 182-509-0005, 182-509-0015, 182-509-0025, 182-509-0030, 182-509-0035, 182-509-0045, 182-509-0055, 182-509-0065, 182-509-0080, 182-509-0085, 182-509-0095, 182-509-0100, 182-509-0110, 182-509-0135, 182-509-0155, 182-509-0165, 182-509-0175, 182-509-0200, 182-509-0205, 182-509-0210, 182-509-0225, 182-523-0110, 182-523-0120 and 182-550-5125; and amending WAC 182-508-0005, 182-508-0150, 182-523-0100, 182-523-0130, 182-534-0100, 182-550-1200, 182-550-1700, 182-550-2521, 182-550-2650, and 182-550-6700.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Other Authority: Patient Protection and Affordable Care Act (Public Law 111-148); 42 C.F.R. § 431, 435, and 457; and 45 C.F.R. § 155.
Adopted under notice filed as WSR 14-10-079 on May 6, 2014.
Changes Other than Editing from Proposed to Adopted Version: The following changes were made from the version filed as WSR 14-10-079 on May 6, 2014:
WAC 182-508-0005: Changed title: "Eligibility for Washington apple health medical care services—Eligibility and scope of coverage."
(1) A person is eligible for state-funded Washington apple health (WAH) medical care services (MCS) coverage to the extent of available funds if the person is:
(a) Determined by the department of social and health services to be eligible for benefits under either the aged, blind, or disabled program as described in WAC 388-400-0060 or the housing and essential needs referral program as described in WAC 388-400-0070; and
(b) Not eligible for another federally funded categorically needy (CN) (as defined in WAC 182-500-0020) or alternative benefits plan (ABP) (as defined in WAC 182-500-0010) WAH program.
(2) A person is not eligible for WAH-MCS if he or she is eligible for federally funded or federally matched programs (see WAC 182-503-0505(2)). If an enrollment cap exists under WAC 182-508-0150, a waiting list of persons may be established.
(3) A person's period of eligibility for MCS is the same as either the person's period of eligibility for the aged, blind, or disabled program as described in WAC 388-449-0150 or the person's incapacity authorization period for the housing and essential needs referral program as described in WAC 388-447-0110.
(4) The MCS program covers only the medically necessary services identified in WAC 182-501-0060.
(5) The MCS program does not cover medical services received outside the state of Washington unless the medical services are provided in a border city listed in WAC 182-501-0175.
WAC 182-546-5550: Section has been removed from this proposal.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 10, Repealed 65; 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 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 10, Repealed 65.
Date Adopted: July 24, 2014.
Kevin M. Sullivan
Rules Coordinator
REPEALER
The following sections of the Washington Administrative Code are repealed:
REPEALER
The following sections of the Washington Administrative Code are repealed:
REPEALER
The following section of the Washington Administrative Code is repealed:
AMENDATORY SECTION (Amending WSR 12-19-051, filed 9/13/12, effective 10/14/12)
WAC 182-508-0005 Eligibility for Washington apple health medical care services eligibility and scope of coverage.
(1) ((An individual)) A person is eligible for state-funded Washington apple health (WAH) medical care services (MCS) ((benefits)) coverage to the extent of available funds if the ((individual)) person is:
(a) ((Completes an interview with the agency or its designee;
(b) Is incapacitated as required under WAC 182-508-0010 through 182-508-0120;
(c) Is at least eighteen years old or, if under eighteen, a member of a married couple;
(d) Is in financial need according to MCS' income and resource rules in chapter 182-509 WAC. The agency or the agency's designee determines who is in the individual's assistance unit according to WAC 182-506-0020;
(e) Meets the medical care services citizenship/alien status requirements under WAC 182-503-0532;
(f) Provides a Social Security number as required under WAC 388-476-0005;
(g) Resides in the state of Washington as required under WAC 182-503-0520;
(h) Reports changes of circumstances as required under WAC 182-504-0100; and
(i) Completes a midcertification review and provides proof of any changes as required under WAC 182-504-0040.
(2) An individual is not eligible for MCS benefits if the individual:
(a) Is eligible for temporary assistance for needy families (TANF) benefits.
(b) Refuses or fails to meet a TANF rule without good cause.
(c) Refuses to or fails to cooperate in obtaining federal aid assistance without good cause.
(d) Refuses or fails to participate in drug or alcohol treatment as required in WAC 182-508-0220.
(e) Is eligible for supplemental security income (SSI) benefits.
(f) Is an ineligible spouse of an SSI recipient.
(g) Refuses or fails to follow a Social Security Administration (SSA) program rule or application requirement without good cause and SSA denied or terminated the individual's benefits.
(h) Is fleeing to avoid prosecution of, or to avoid custody or confinement for conviction of, a felony, or an attempt to commit a felony as described in WAC 182-503-0560.
(i) Is eligible for a categorically needy (CN) medicaid program.
(j) Refuses or fails to cooperate with CN medicaid program rules or requirements.
(3) An individual who resides in a public institution and meets all other requirements may be eligible for MCS depending on the type of institution. A "public institution" is an institution that is supported by public funds, and a governmental unit either is responsible for it or exercises administrative control over it.
(a) An individual may be eligible for MCS if the individual is:
(i) A patient in a public medical institution; or
(ii) A patient in a public mental institution and is sixty-five years of age or older.
(b) An individual is not eligible for MCS when the individual is in the custody of or confined in a public institution such as a state penitentiary or county jail, including placement:
(i) In a work release program; or
(ii) Outside of the institution including home detention.
(4))) Determined by the department of social and health services to be eligible for benefits under either the aged, blind, or disabled program as described in WAC 388-400-0060 or the housing and essential needs referral program as described in WAC 388-400-0070; and
(b) Not eligible for another federally funded categorically needy (CN) (as defined in WAC 182-500-0020) or alternative benefits plan (ABP) (as defined in WAC 182-500-0010) WAH program.
(2) If an enrollment cap exists under WAC 182-508-0150, a waiting list of persons may be established.
(3) A person's period of eligibility for MCS is the same as either the person's period of eligibility for the aged, blind, or disabled program as described in WAC 388-449-0150 or the person's incapacity authorization period for the housing and essential needs referral program as described in WAC 388-447-0110.
(4) The MCS program covers only the medically necessary services defined in WAC 182-501-0060.
(5) The MCS program does not cover medical services received outside the state of Washington unless the medical services are provided in a border city listed in WAC 182-501-0175.
AMENDATORY SECTION (Amending WSR 12-19-051, filed 9/13/12, effective 10/14/12)
WAC 182-508-0150 Enrollment cap for medical care services (MCS).
(1) Enrollment in medical care services (MCS) coverage is subject to available funds.
(2) The agency may limit enrollment into MCS coverage by implementing an enrollment cap and ((waiting)) wait list.
(3) If ((an individual)) a person is denied MCS coverage due to an enrollment cap:
(a) The ((individual)) person is added to the MCS ((waiting)) wait list based on the date the ((individual)) person applied.
(b) Applicants with the oldest application date will be the first to receive an opportunity for enrollment when MCS coverage is available as long as the person remains on the MCS wait list.
(4) ((An individual)) A person is exempted from the enrollment cap and wait list rules when:
(a) MCS was terminated due to agency error;
(b) The ((individual)) person is in the thirty-day reconsideration period for incapacity reviews under WAC ((182-508-0160(4))) 388-447-0110(4); ((or))
(c) The ((individual)) person is being terminated from a CN medical program and was receiving and eligible for CN coverage prior to the date a wait list was implemented and ((the following conditions are met:
(i) The individual met financial and program eligibility criteria for MCS at the time their CN coverage ended; and
(ii) The individual met the incapacity criteria for MCS at the time their CN coverage ended.
(d) The individual applied for medical coverage and an eligibility decision was not completed prior to the enrollment cap effective date.
(5) If the individual is sent an offer for MCS enrollment, the individual must submit a completed application no later than the last day of the month following the month of enrollment offer. The individual must reapply within this time period and subsequently be determined eligible before MCS coverage can begin. The individual must reapply and requalify even if the individual was previously determined eligible for MCS.
(6))) at the time their CN coverage ended, the person met eligibility criteria to receive benefits under either the aged, blind, or disabled program as described in WAC 388-400-0060 or the housing and essential needs referral program as described in WAC 388-400-0070; or
(d) The person applied for a determination by the department of social and health services (DSHS) to be eligible for benefits under either the aged, blind, or disabled program as described in WAC 388-400-0060 or the housing and essential needs referral program as described in WAC 388-400-0070, but the determination was not completed prior to the enrollment cap effective date.
(5) The ((individual)) person is removed from the MCS wait list if the ((individual)) person:
(a) Is not a Washington resident;
(b) Is deceased;
(c) Requests removal from the wait list;
(d) ((Fails to submit an application after an enrollment offer is sent as described in subsection (5) of this section;
(e) Reapplies as described in subsection (5) of this section, but does not qualify for MCS; or
(f))) Is found eligible for categorically or medically needy coverage; or
(e) Is no longer determined by DSHS to be eligible for benefits under either the aged, blind, or disabled program as described in WAC 388-400-0060 or the housing and essential needs referral program as described in WAC 388-400-0070.
REPEALER
The following sections of the Washington Administrative Code are repealed:
REPEALER
The following sections of the Washington Administrative Code are repealed:
REPEALER
The following section of the Washington Administrative Code is repealed:
AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)
WAC 182-523-0100 ((Medical extensions—Eligibility.)) Washington apple health—Medical extension.
(((1) A family who received temporary assistance for needy families (TANF), or family medical program in any three of the last six months in the state of Washington is eligible for extended medical benefits when they become ineligible for their current medical program because the family receives:
(a) Child or spousal support, which exceeds the payment standard described in WAC 388-478-0065, and they are not eligible for any other categorically needy (CN) medical program; or
(b) Increased earned income, resulting in income exceeding the CN income standard described in WAC 388-478-0065.
(2) A family is eligible to receive extended medical benefits beginning the month after termination from TANF cash or family medical program for:
(a) Four months for a family described in subsection (1)(a) of this section; or
(b) Up to twelve months, in two six-month segments, for a family described in subsection (1)(b) of this section. For the purposes of this chapter, months one through six are the initial six-month extension period. Months seven through twelve are the second six-month extension period.
(3) A family member is eligible to receive six months of medical extension benefits as described in subsection (2)(b) of this section unless:
(a) The individual family member:
(i) Moves out of state;
(ii) Dies;
(iii) Becomes an inmate of a public institution;
(iv) Leaves the household; or
(v) Does not cooperate, without good cause, with the division of child support or with third-party liability requirements.
(b) The family:
(i) Moves out of state;
(ii) Loses contact with the department or the department does not know the whereabouts of the family; or
(iii) No longer includes a child as defined in WAC 388-404-0005(1).
(4) A family member is eligible to receive the second six months of medical extension benefits as described in subsection (2)(b) of this section unless:
(a) The family is no longer eligible for the reasons described in subsection (3)(a) or (b); or
(b) The individual family member is the caretaker adult who:
(i) Stops working or whose earned income stops;
(ii) Does not, without good cause, complete and return the completed medical extension report or otherwise provide the required income and child care information; or
(iii) Does not, without good cause, pay the billed premium amount for one month.
(5) A family described in subsection (3) will not receive medical extension benefits for any family member who has been found ineligible for TANF/SFA cash because of fraud in any of the six months prior to the medical extension period.
(6) For the purposes of this chapter, only individual family members that are eligible for medicaid are certified to receive medical benefits under this program.)) (1) A parent or caretaker relative who received coverage under Washington apple health (WAH) for parents and caretaker relatives, (described in WAC 182-505-0240), in any three of the last six months is eligible, along with all dependent children living in the household, for twelve months' extended health care coverage if the person becomes ineligible for his or her current coverage due to increased earnings or hours of employment.
(2) A person remains eligible for WAH medical extension unless:
(a) The person:
(i) Moves out of state;
(ii) Dies;
(iii) Becomes an inmate of a public institution; or
(iv) Leaves the household.
(b) The family:
(i) Moves out of state;
(ii) Loses contact with the agency or its designee or the whereabouts of the family are unknown; or
(iii) No longer includes an eligible dependent child as defined in WAC 182-503-0565(2).
(3) When a person or family is determined ineligible for WAH coverage under subsection (2)(a)(i) through (iii) or (b)(i) or (ii) of this section during the medical extension period, the agency or its designee redetermines eligibility for the remaining household members as described in WAC 182-504-0125 and sends written notice as described in chapter 182-518 WAC before WAH medical extension is terminated.
AMENDATORY SECTION (Amending WSR 12-13-056, filed 6/15/12, effective 7/1/12)
WAC 182-523-0130 Medical extension—Redetermination.
(1) When the ((department)) agency or its designee determines the family or an individual family member is ineligible during the medical extension period, the ((department)) agency or its designee must determine if they are eligible for another medical program.
(2) Children are eligible for twelve month continuous eligibility beginning with the first month of the medical extension period.
(3) When a family reports a reduction of income, the family may be eligible for ((a family medical program)) the Washington apple health for parents and caretaker relatives program (described in WAC 182-505-0240) instead of medical extension benefits.
(4) When a medical extension period is ending, the family is required to complete a renewal of eligibility as described in WAC 182-504-0035.
(5) Postpartum and family planning extensions are described in WAC ((388-462-0015)) 182-505-0115.
REPEALER
The following sections of the Washington Administrative Code are repealed:
AMENDATORY SECTION (Amending WSR 12-22-046, filed 11/2/12, effective 12/3/12)
WAC 182-534-0100 EPSDT.
(1) Persons who are eligible for medicaid((, except those identified in subsection (4) of this section,)) are eligible for coverage through the early and periodic screening, diagnosis, and treatment (EPSDT) program up through the day before their twenty-first birthday.
(2) Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part 441, Subpart B which were in effect as of January 1, 1998.
(a) The standard for coverage for EPSDT is that the services, treatment or other measures are:
(i) Medically necessary;
(ii) Safe and effective; and
(iii) Not experimental.
(b) EPSDT services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program. Examples of service limits which do not apply to the EPSDT program are the specific numerical limits in WAC 182-545-200.
(c) Services not otherwise covered under the medicaid program are available to children under EPSDT. The services, treatments and other measures which are available include but are not limited to:
(i) Nutritional counseling;
(ii) Chiropractic care;
(iii) Orthodontics; and
(iv) Occupational therapy (not otherwise covered under the MN program).
(d) Prior authorization and referral requirements are imposed on medical service providers under EPSDT. Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.
(3) Transportation requirements of 42 C.F.R. 441, Subpart B are met through a contract with transportation brokers throughout the state.
(((4) Persons who are nineteen through twenty years of age who are eligible for any of the following programs that receive medicaid funding under the transitional bridge demonstration waiver allowed under section 1115 (a)(2) of the Social Security Act are not eligible for EPSDT services:
(a) Basic health;
(b) Medical care services; or
(c) Alcohol and Drug Addiction Treatment and Support Act (ADATSA).))
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)) person eligible under a ((medical assistance)) Washington apple health (WAH) program that is paid by the ((department's)) agency's fee-for-services payment system must be within the scope of the ((client's medical assistance)) person's WAH program. Coverage restriction includes, but is not limited to the following:
(1) ((Clients)) Persons 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)) Persons covered by primary care case management are subject to the ((clients')) persons' primary care physicians' approval for hospital services;
(3) For emergency care exemptions for ((clients)) persons described in subsections (1) and (2) of this section, see WAC ((388-538-100.)) 182-538-100;
(4) ((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 health care is not covered for clients under the PII program; and
(b) Bordering city hospitals and critical border hospitals are not considered instate hospitals for PII program claims.
(5))) Health care services provided by a hospital located out-of-state are:
(a) Not covered for ((clients)) persons eligible under the medical care services (MCS) program. However, ((clients)) persons 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 ((SCHIP clients)) CHIP persons 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)) CHIP persons when prior authorized by the ((department)) agency 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 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)) CHIP clients based on authorization by a ((mental health division (MHD))) division of behavioral health and recovery (DBHR) designee.
(((6))) (5) See WAC ((388-550-1100)) 182-550-1100 for hospital services for chemical-using pregnant (CUP) women((.));
(((7))) (6) 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))) (7) For ((clients)) persons eligible for both medicare and medicaid (dual eligibles), the ((department)) agency pays deductibles and coinsurance, unless the ((client)) person has exhausted his or her medicare Part A benefits. If medicare benefits are exhausted, the ((department)) agency pays for hospitalization for such ((clients)) persons subject to ((department)) agency rules. See also chapter ((388-502)) 182-502 WAC((.));
(((9))) (8) The ((department)) agency does not pay for covered inpatient hospital services for a ((medical assistance)) WAH client:
(a) Who is discharged from a hospital by a physician because the ((client)) person 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))) (9) If the hospital's utilization review committee determines the ((client's)) person's stay is beyond the period of medical necessity, as described in subsection (((9))) (8) of this section, the hospital must:
(a) Inform the ((client)) person in a written notice that the ((department)) agency is not responsible for payment (42 C.F.R. 456);
(b) Comply with the requirements in WAC ((388-502-0160)) 182-502-0160 in order to bill the ((client)) person for the service(s); and
(c) Send a copy of the written notice in (a) of this subsection to the ((department)) agency.
(((11))) (10) Other coverage restrictions, as determined by the ((department)) agency.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-550-1700 Authorization and utilization review (UR) of inpatient and outpatient hospital services.
(1) This section applies to the ((department's)) agency's authorization and utilization review (UR) of inpatient and outpatient hospital services provided to ((medical assistance)) Washington apple health (WAH) clients receiving services through the fee-for-service program. For clients eligible under other ((medical assistance)) WAH programs, see chapter ((388-538)) 182-538 WAC for managed care organizations, ((chapters 388-800 and 388-810 WAC for the Alcohol and Drug Addiction Treatment and Support Act (ADATSA),)) and chapter 388-865 WAC for mental health treatment programs coordinated through the ((mental health division)) department of social and health services' division of behavioral health and recovery or its designee(())). See chapter ((388-546)) 182-546 WAC for transportation services.
(2) All hospital services paid for by the ((department)) agency are subject to UR for medical necessity, appropriate level of care, and program compliance.
(3) Authorization for inpatient and outpatient hospital services is valid only if a client is eligible for covered services on the date of service. Authorization does not guarantee payment.
(4) The ((department)) agency will deny, recover, or adjust hospital payments if the ((department)) agency or its designee determines, as a result of UR, that a hospital service does not meet the requirements in federal regulations and WAC.
(5) The ((department)) agency may perform one or more types of UR described in subsection (6) of this section.
(6) The ((department's)) agency's UR:
(a) Is a concurrent, prospective, and/or retrospective (including postpay and prepay) formal evaluation of a client's documented medical care to assure that the services provided are proper and necessary and of good quality. The review considers the appropriateness of the place of care, level of care, and the duration, frequency or quantity of services provided in relation to the conditions(s) being treated; and
(b) Includes one or more of the following:
(i) "Concurrent utilization review"—An evaluation performed by the ((department)) agency or its designee during a client's course of care. A continued stay review performed during the client's hospitalization is a form of concurrent UR;
(ii) "Prospective utilization review"—An evaluation performed by the ((department)) agency or its designee prior to the provision of health care services. Preadmission authorization is a form of prospective UR; and
(iii) "Retrospective utilization review"—An evaluation performed by the ((department)) agency or its designee following the provision of health care services that includes both a post-payment retrospective UR (performed after health care services are provided and paid), and a prepayment retrospective UR (performed after health care services are provided but prior to payment). Retrospective UR is routinely performed as an audit function.
(7) During the UR process, the ((department)) agency or its designee notifies the appropriate oversight entity if either of the following is identified:
(a) A quality of care concern; or
(b) Fraudulent conduct.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-550-2521 Client eligibility requirements for acute PM&R services.
(1) Only a client who is eligible for one of the ((following)) Washington apple health programs may receive acute PM&R services, subject to the restrictions and limitations in this section and WAC ((388-550-2501, 388-550-2511, 388-550-2531, 388-550-2541, 388-550-2551, 388-550-2561, 388-550-3381)) 182-550-2501, 182-550-2511, 182-550-2531, 182-550-2541, 182-550-2551, 182-550-2561, 182-550-3381, and other rules:
(a) Categorically needy program (CNP);
(b) ((State)) Children's health insurance program (((SCHIP))) (CHIP);
(c) ((Limited casualty program -)) Medically needy program (LCP-MNP);
(d) Alien emergency medical (AEM)(CNP);
(e) Alien emergency medical (AEM)(LCP-MNP);
(f) ((General assistance unemployable (GA-U - No out-of-state care); or
(g) Alcoholism and Drug Addiction Treatment and Support Act (ADATSA))) Medical care services.
(2) If a client is enrolled in ((a department)) an agency managed care organization (MCO) plan at the time of acute care admission, that plan pays for and coordinates acute PM&R services as appropriate.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-550-2650 Base community psychiatric hospitalization payment method for medicaid and ((SCHIP)) CHIP clients and nonmedicaid and ((non-SCHIP)) non-CHIP clients.
(1) Effective for dates of admission from July 1, 2005 through June 30, 2007, and in accordance with legislative directive, the ((department)) agency implemented two separate base community psychiatric hospitalization payment rates, one for medicaid and ((SCHIP)) children's health insurance program (CHIP) clients and one for nonmedicaid and ((non-SCHIP)) non-CHIP clients. Effective for dates of admission on and after July 1, 2007, the base community psychiatric hospitalization payment method for medicaid and ((SCHIP)) CHIP clients and nonmedicaid and ((non-SCHIP)) non-CHIP clients is no longer used. (For the purpose of this section, a "nonmedicaid or ((non-SCHIP)) non-CHIP client" is defined as a client eligible under the ((general assistance-unemployable (GA-U) program, the Alcoholism and Drug Addiction Treatment and Support Act (ADATSA), the psychiatric indigent inpatient (PII) program, or other state-administered)) medical care services (MCS) program, as determined by the ((department)) agency.)
(a) The medicaid base community psychiatric hospital payment rate is a minimum per diem for claims for psychiatric services provided to medicaid and ((SCHIP)) CHIP covered patients, paid to hospitals that accept commitments under the Involuntary Treatment Act (ITA).
(b) The nonmedicaid base community psychiatric hospital payment rate is a minimum allowable per diem for claims for psychiatric services provided to indigent patients paid to hospitals that accept commitments under the ITA.
(2) For the purposes of this section, "allowable" means the calculated allowed amount for payment based on the payment method before adjustments, deductions, or add-ons.
(3) To be eligible for payment under the base community psychiatric hospitalization payment method:
(a) A client's inpatient psychiatric voluntary hospitalization must:
(i) Be medically necessary as defined in WAC ((388-500-0005)) 182-500-0070. In addition, the ((department)) agency considers medical necessity to be met when:
(A) Ambulatory care resources available in the community do not meet the treatment needs of the client;
(B) Proper treatment of the client's psychiatric condition requires services on an inpatient basis under the direction of a physician;
(C) The inpatient services can be reasonably expected to improve the client's condition or prevent further regression so that the services will no longer be needed; and
(D) The client, at the time of admission, is diagnosed as having an emotional/behavioral disturbance as a result of a mental disorder as defined in the current published Diagnostic and Statistical Manual of the American Psychiatric Association. The ((department)) agency does not consider detoxification to be psychiatric in nature.
(ii) Be approved by the professional in charge of the hospital or hospital unit.
(iii) Be authorized by the appropriate ((mental health division (MHD))) division of behavioral health and recovery (DBHR) designee prior to admission for covered diagnoses.
(iv) Meet the criteria in WAC ((388-550-2600)) 182-550-2600.
(b) A client's inpatient psychiatric involuntary hospitalization must:
(ii) Be certified by a ((MHD)) DBHR designee.
(iii) Be approved by the professional in charge of the hospital or hospital unit.
(iv) Be prior authorized by the regional support network (RSN) or its designee.
(v) Meet the criteria in WAC ((388-550-2600)) 182-550-2600.
(4) The provider requesting payment must complete the appropriate sections of the Involuntary Treatment Act patient claim information (form DSHS 13-628) in triplicate and route both the form and each claim form submitted for payment, to the county involuntary treatment office.
(5) Payment for all claims is based on covered days within a client's approved length of stay (LOS), subject to client eligibility and ((department-covered)) agency-covered services.
(6) The medicaid base community psychiatric hospitalization payment rate applies only to a medicaid or ((SCHIP)) CHIP client admitted to a nonstate-owned free-standing psychiatric hospital located in Washington state.
(7) The nonmedicaid base community psychiatric hospitalization payment rate applies only to a nonmedicaid or ((SCHIP)) CHIP client admitted to a hospital:
(a) Designated by the ((department)) agency as an ITA-certified hospital; or
(b) That has ((a department-certified)) an agency-certified ITA bed that was used to provide ITA services at the time of the nonmedicaid or ((non-SCHIP)) non-CHIP admission.
(8) For inpatient hospital psychiatric services provided to eligible clients for dates of admission on and after July 1, 2005, through June 30, 2007, the ((department)) agency pays:
(a) A hospital's department of health (DOH)-certified distinct psychiatric unit as follows:
(i) For medicaid and ((SCHIP)) CHIP clients, inpatient hospital psychiatric services are paid using the ((department-specific)) agency-specific nondiagnosis related group (DRG) payment method.
(ii) For nonmedicaid and ((non-SCHIP)) non-CHIP clients, the allowable for inpatient hospital psychiatric services is the greater of:
(A) The state-administered program DRG allowable (including the high cost outlier allowable, if applicable), or the ((department-specified)) agency-specified non-DRG payment method if no relative weight exists for the DRG in the ((department's)) agency's payment system; or
(B) The nonmedicaid base community psychiatric hospitalization payment rate multiplied by the covered days.
(b) A hospital without a DOH-certified distinct psychiatric unit as follows:
(i) For medicaid and ((SCHIP)) CHIP clients, inpatient hospital psychiatric services are paid using:
(A) The DRG payment method; or
(B) The ((department-specified)) agency-specified non-DRG payment method if no relative weight exists for the DRG in the ((department's)) agency's payment system.
(ii) For nonmedicaid and ((SCHIP)) CHIP clients, the allowable for inpatient hospital psychiatric services is the greater of:
(A) The state-administered program DRG allowable (including the high cost outlier allowable, if applicable), or the ((department-specified)) agency-specified non-DRG payment method if no relative weight exists for the DRG in the ((department's)) agency's payment system; or
(B) The nonmedicaid base community psychiatric hospitalization payment rate multiplied by the covered days.
(c) A nonstate-owned free-standing psychiatric hospital as follows:
(i) For medicaid and ((SCHIP)) CHIP clients, inpatient hospital psychiatric services are paid using as the allowable, the greater of:
(A) The ratio of costs-to-charges (RCC) allowable; or
(B) The medicaid base community psychiatric hospitalization payment rate multiplied by covered days.
(ii) For nonmedicaid and ((non-SCHIP)) non-CHIP clients, inpatient hospital psychiatric services are paid the same as for medicaid and ((SCHIP)) CHIP clients, except the base community inpatient psychiatric hospital payment rate is the nonmedicaid rate, and the RCC allowable is the state-administered program RCC allowable.
(d) A hospital, or a distinct psychiatric unit of a hospital, that is participating in the certified public expenditure (CPE) payment program, as follows:
(i) For medicaid and ((SCHIP)) CHIP clients, inpatient hospital psychiatric services are paid using the methods identified in WAC ((388-550-4650)) 182-550-4650.
(ii) For nonmedicaid and ((non-SCHIP)) non-CHIP clients, inpatient hospital psychiatric services are paid using the methods identified in WAC ((388-550-4650)) 182-550-4650 in conjunction with the nonmedicaid base community psychiatric hospitalization payment rate multiplied by covered days.
(e) A hospital, or a distinct psychiatric unit of a hospital, that is participating in the critical access hospital (CAH) program, as follows:
(i) For medicaid and ((SCHIP)) CHIP clients, inpatient hospital psychiatric services are paid using the ((department-specified)) agency-specified non-DRG payment method.
(ii) For nonmedicaid (([and] non-SCHIP)) and non-CHIP clients, inpatient hospital psychiatric services are paid using the ((department-specified)) agency-specified non-DRG payment method.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-550-6700 Hospital services provided out-of-state.
(1) The ((department)) agency pays:
(a) For dates of admission before August 1, 2007, for only emergency care for an eligible medicaid and ((SCHIP)) CHIP client who goes to another state, except specified border cities, specifically for the purpose of obtaining medical care that is available in the state of Washington. See WAC ((388-501-0175)) 182-501-0175 for a list of border cities.
(b) For dates of admission on and after August 1, 2007, for both emergency and nonemergency out-of-state hospital services, including those provided in bordering city hospitals and critical border hospitals, for eligible medicaid and ((SCHIP)) CHIP clients based on the medical necessity and utilization review standards and limits established by the ((department)) agency.
(i) Prior authorization by the ((department)) agency is required for the nonemergency out-of-state hospital medical care provided to medicaid and ((SCHIP)) CHIP clients.
(ii) Bordering city hospitals are considered the same:
(A) As instate hospitals for coverage of hospital services; and
(B) As out-of-state hospitals for payment methodology. ((Department)) Agency designated critical border hospitals are paid as instate hospitals. See WAC ((388-550-3900 and 388-550-4000)) 182-550-3900 and 182-550-4000.
(c) For out-of-state voluntary psychiatric inpatient hospital services for eligible medicaid and ((SCHIP)) CHIP clients based on authorization by a ((mental health)) division of behavioral health designee.
(d) Based on the ((department's)) agency's limitations on hospital coverage under WAC ((388-550-1100 and 388-550-1200)) 182-550-1100 and 182-550-1200 and other applicable rules.
(2) The ((department)) agency authorizes and pays for comparable hospital services for a medicaid and ((SCHIP)) CHIP client who is temporarily outside the state to the same extent that such services are furnished to an eligible medicaid client in the state, subject to the exceptions and limitations in this section. See WAC ((388-550-3900 and 388-550-4000)) 182-550-3900 and 182-550-4000.
(3) The ((department)) agency limits out-of-state hospital coverage for ((clients)) persons eligible under state-administered programs as follows:
(a) For a ((client eligible under the psychiatric indigent inpatient (PII) program or)) person who receives services under the Involuntary Treatment Act (ITA), the ((department)) agency does not pay for hospital services provided in any hospital outside the state of Washington (including bordering city and critical border hospitals).
(b) For a ((client)) person eligible under ((a department's)) an agency's general assistance program, the ((department)) agency pays only for hospital services covered under the ((client's)) person's medical care services' program scope of care that are provided in a bordering city hospital or a critical border hospital. The ((department)) agency does not pay for hospital services provided to ((clients)) persons eligible under a general assistance program in other hospitals located outside the state of Washington. The ((department)) agency or its designee may require prior authorization for hospital services provided in a bordering city hospital or a critical border hospital. See WAC ((388-550-1200)) 182-550-1200.
(4) The ((department)) agency covers hospital care provided to medicaid or ((SCHIP)) CHIP clients in areas of Canada as described in WAC ((388-501-0180)) 182-501-0180, and based on the limitations described in the state plan.
(5) The ((department)) agency may review all cases involving out-of-state hospital services, including those provided in bordering city hospitals and critical border hospitals, to determine whether the services are within the scope of the ((client's medical assistance)) person's WAH program.
(6) If the ((client)) person can claim deductible or coinsurance portions of medicare, the provider must submit the claim to the intermediary or carrier in the provider's own state on the appropriate medicare billing form. If the state of Washington is checked on the form as the party responsible for medical bills, the intermediary or carrier may bill on behalf of the provider or may return the claim to the provider for submission to the state of Washington.
(7) For payment for out-of-state inpatient hospital services, see WAC ((388-550-3900 and 388-550-4000)) 182-550-3900 and 182-550-4000.
(8) Out-of-state providers, including bordering city hospitals and critical border hospitals, must present final charges to the ((department)) agency within three hundred sixty-five days of the "statement covers period from date" shown on the claim. The state of Washington is not liable for payment of charges received beyond three hundred sixty-five days from the "statement covers period from date" shown on the claim.
REPEALER
The following section of the Washington Administrative Code is repealed:
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