WSR 23-08-085
PERMANENT RULES
HEALTH CARE AUTHORITY
[Filed April 5, 2023, 10:10 a.m., effective May 6, 2023]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The health care authority (HCA) is amending WAC 182-550-4400 to change a reference to the chemical-using pregnant (CUP) women program to the substance-using pregnant people (SUPP) program in subsection (2)(b). HCA is also amending subsection (2)(g) to reflect that HCA no longer denies payment for claims grouped to diagnosis-related group 469 or 470.
Citation of Rules Affected by this Order: Amending WAC 182-550-4400.
Adopted under notice filed as WSR 23-06-056 on February 27, 2023.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: April 5, 2023.
Wendy Barcus
Rules Coordinator
OTS-4326.3
AMENDATORY SECTION(Amending WSR 21-15-128, filed 7/21/21, effective 8/21/21)
WAC 182-550-4400Services—Exempt from DRG payment.
(1) Inpatient services are exempt from the diagnosis-related group (DRG) payment method only if they qualify for payment methods specifically mentioned in other sections of this chapter or in this section.
(2) Subject to the restrictions and limitations in this section, the agency exempts the following services for medicaid and CHIP clients from the DRG payment method. This policy also applies to covered services paid through medical care services (MCS) and any other state-administered program, except when otherwise indicated in this section. The exempt services are:
(a) Withdrawal management services when provided in a hospital having a withdrawal management provider agreement with the agency to perform these services.
(b) Hospital-based intensive inpatient withdrawal management, medical stabilization, and drug treatment services provided to ((chemical-using pregnant (CUP) women by a certified))substance-using pregnant people (SUPP) clients by an agency-approved hospital. These are medicaid program services and are not covered or funded by the agency through MCS or any other state-administered program.
(c) Acute physical medicine and rehabilitation (acute PM&R) services.
(d) Psychiatric services. An agency designee that arranges to pay a hospital directly for psychiatric services may use the agency's payment methods or contract with the hospital to pay using different methods.
(e) Chronic pain management treatment provided in a hospital approved by the agency to provide that service.
(f) Administrative day services. The agency pays administrative days for one or more days of a hospital stay in which an acute inpatient or observation level of care is not medically necessary, and a lower level of care is appropriate. The administrative day rate is based on the statewide average daily medicaid nursing facility rate, which is adjusted annually. The agency may designate part of a client's stay to be paid an administrative day rate upon review of the claim or the client's medical record, or both.
(g) Inpatient services recorded on a claim grouped by the agency to a DRG for which the agency has not published an all-patient DRG (AP-DRG) or all-patient refined DRG (APR-DRG) relative weight. The agency will deny payment for claims grouped to ((DRG 469, DRG 470,)) APR DRG 955((,)) or APR DRG 956.
(h) Organ transplants that involve heart, intestine, kidney, liver, lung, allogeneic bone marrow, autologous bone marrow, pancreas, or simultaneous kidney/pancreas. The agency pays hospitals for these organ transplants using the ratio of costs-to-charges (RCC) payment method. The agency maintains a list of DRGs which qualify as transplants on the agency's website.