WSR 21-24-023
PROPOSED RULES
HEALTH CARE AUTHORITY
[Filed November 19, 2021, 1:45 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 21-20-034.
Title of Rule and Other Identifying Information: WAC 182-550-4300 Hospitals and units exempt from the DRG payment method.
Hearing Location(s): On January 4, 2022, at 10:00 a.m. The health care authority (HCA) remains closed in response to the coronavirus disease 2019 (COVID-19) public health emergency. Until further notice, HCA continues to hold public hearings virtually without a physical meeting place. This promotes social distancing and the safety of Washington state residents. To attend the virtual public hearing, you must register in advance https://zoom.us/webinar/register/WN_EO-r4q2sQmeswJiqMwS3Rw. After registering, you will receive a confirmation email containing information about joining the public hearing.
Date of Intended Adoption: Not sooner than January 5, 2022.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by January 4, 2022.
Assistance for Persons with Disabilities: Contact HCA rules coordinator, phone 360-725-1306, fax 360-586-9727, telecommunication[s] relay service 711, email arc@hca.wa.gov, by December 23, 2021.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending WAC 182-550-4300 to align the rule with the medicaid state plan, which does not have specific time limitations on inpatient withdrawal management services.
Reasons Supporting Proposal: See purpose.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Statute Being Implemented: RCW 41.05.021, 41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: Not applicable.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Brian Jensen, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-0815; Implementation and Enforcement: Cynde Rivers, P.O. Box 45502, Olympia, WA 98504-5502, 360-725-5282.
A school district fiscal impact statement is not required under RCW 28A.305.135.
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.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The proposed rule removes limitations on a client medical benefit and does not impose costs on small businesses.
November 19, 2021
Wendy Barcus
Rules Coordinator
OTS-3422.1
AMENDATORY SECTION(Amending WSR 21-15-128, filed 7/21/21, effective 8/21/21)
WAC 182-550-4300Hospitals and units exempt from the DRG payment method.
(1) Except when otherwise specified, inpatient services provided by hospitals and units that are exempt from the diagnosis-related group (DRG) payment method are paid under the ratio of costs-to-charges (RCC) payment method described in WAC 182-550-4500, the per diem payment method described in WAC 182-550-3000, the per case rate payment method described in WAC 182-550-3000, or other payment methods identified in this chapter (e.g., long term acute care (LTAC), certified public expenditure (CPE), critical access hospital (CAH), etc.). Inpatient services provided by hospitals and units are exempt from the DRG payment method only if they qualify for payment methods specifically mentioned in other sections of this chapter or in this section.
(2) The agency exempts the following hospitals, units, and services from the DRG payment method for inpatient services provided to clients eligible for Washington apple health:
(a) Hospitals participating in the agency's certified public expenditure (CPE) payment program (see WAC 182-550-4650);
(b) Hospitals participating in the agency's critical access hospital program (see WAC 182-550-2598);
(c) Rehabilitation services. All rehabilitation services are paid through the per diem payment method except as indicated in (a), (b), and (d) of this subsection (see WAC 182-550-3000);
(d) Military hospitals when no other specific arrangements have been made with the agency. The agency, or the military hospital, may elect or arrange for one of the following payment methods in lieu of the RCC payment method:
(i) Per diem payment method; or
(ii) DRG payment method; and
(e) Psychiatric services. All psychiatric services are paid through the per diem payment method except as indicated in (a), (b), and (d) of this subsection (see WAC 182-550-3000). An agency designee that arranges to directly pay a hospital and/or a designated distinct psychiatric unit of a hospital may use the agency's payment methods or contract with the hospital to pay using different methods.
(3) Inpatient psychiatric services, Involuntary Treatment Act services, and withdrawal management services provided in out-of-state hospitals are not covered or paid by the agency or the agency's designee. The agency does not cover or pay for other hospital services provided to clients eligible for those services in the following programs, when the services are provided in out-of-state hospitals that are not in designated bordering cities:
(a) Medical care services; and
(b) Other state-administered programs.
(4) The agency has established an average length of stay (ALOS) for each DRG classification and publishes it on the agency's website. The agency uses the DRG ALOS as a benchmark to authorize and pay inpatient hospital stays exempt from the DRG payment method. When an inpatient hospital stay exceeds the agency's DRG ALOS benchmark or prior authorized LOS:
(a) For a psychiatric inpatient stay, the hospital must obtain approval for additional days beyond the prior authorized days from the agency or the agency's designee who prior authorized the admission. See WAC 182-550-2600;
(b) For an acute physical medicine and rehabilitation (PM&R) or a long term acute care (LTAC) stay, the hospital must obtain approval for additional days beyond the prior authorized days from the agency unit that prior authorized the admission. See WAC 182-550-2561 and 182-550-2590;
(c) For an inpatient hospital stay for withdrawal management for a chemical using pregnant (CUP) client, see WAC 182-550-1100;
(d) For other medical inpatient stays for withdrawal management, see WAC 182-550-1100 ((and subsection (5) of this section));
(e) For an inpatient stay in a certified public expenditure (CPE) hospital, see WAC 182-550-4690; and
(f) For an inpatient hospital stay not identified in (a) through (e) of this subsection, the agency may perform retrospective utilization review to determine if the LOS was medically necessary and at the appropriate level of care.
(((5) If subsection (4)(d) of this section applies to an eligible client, the agency will:
(a) Pay for three-day withdrawal management services for an acute alcoholic condition; or
(b) Pay for five-day withdrawal management services for acute drug addiction when the services are directly related to withdrawal management; and
(c) If WAC 182-550-1100 (5)(b) applies, extend the three- and five-day limitations when the following are true:
(i) The days are billed as covered;
(ii) A medical record is submitted with the claim;
(iii) The medical record clearly documents that the days are medically necessary; and
(iv) The level of care is appropriate according to WAC 182-550-2900.))