Date of Adoption: December 14, 1999.

Purpose: The department has reviewed the rules for compliance with the clear writing principles in the Governor's Executive Order 97-02. The rules have been rewritten for clarity and simplification without making any policy changes. Some rules are being repealed in order to consolidate those policies in new chapters; the new rules replacing repealed rules do not change existing policy.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-0022, 388-87-0020, 388-87-0025, 388-87-0105, 388-87-0250, and amending WAC 388-501-0175, 388-502-0250, 388-530-1800, 388-530-2050, 388-540-001, 388-540-005, 388-540-010, 388-540-020, 388-540-030, 388-540-040, 388-540-050, and 388-540-060.

Statutory Authority for Adoption: RCW 74.04.050, 74.08.090.

Adopted under notice filed as WSR 99-20-111 on October 6, 1999.

Changes Other than Editing from Proposed to Adopted Version: Numbering changes for rules proposed as: WAC 388-502-0250 renumbered as WAC 388-502-0130, proposed new WAC 388-557-0100 renumbered as WAC 388-502-0120.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 5, Amended 12, Repealed 5.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 5, Amended 12, Repealed 5. Effective Date of Rule: Thirty-one days after filing.

December 14, 1999

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

All medical services that are provided to clients of medical care programs are subject to review and approval for reimbursement by the medical assistance administration (MAA).

[]

(1) For the purpose of this section, "liable third party" means:

(a) The tort-feasor or insurer of the tort-feasor, or both; and

(b) Any person who is liable to provide coverage for the illness or injuries for which the medical assistance administration (MAA) is providing assistance or residential care. That liability must be based on any contract or insurance purchased by the client or any other person.

(2) As a condition of medical care eligibility, a client must assign to the state any right the client may have to receive payment from any other third party. An eligible client who receives health care items or services from the state under medical care programs under chapter 74.09 RCW and who has a right to payment from any other third party for those items or services, subrogates that right of payment to the state. This applies except as provided in subsection (3) of this section.

(3) To the extent authorized by a contract executed under RCW 74.09.522, a managed health care plan has the rights and remedies of the department as provided in RCW 43.20B.060 and 70.09.180.

(4) MAA is not responsible to pay for medical care for a client whose personal injuries are caused by the negligence or wrongdoing of another. However, MAA may provide the medical care required as a result of an injury to the client if both of the following apply:

(a) The client is otherwise eligible for medical care; and

(b) No other liable third party has been identified at the time the claim is filed.

(5) The department may pursue its right to recover the value of medical care provided to an eligible client from any liable third party as a subrogee, assignee, or by enforcement of its public assistance lien as provided under RCW 43.20B.040 through 43.20B.070.

(6) Recovery pursuant to the subrogation rights, assignment, or enforcement of the lien granted to the department is not reduced, prorated, or applied to only a portion of a judgment, award, or settlement. The secretary of the department or the secretary's designee must consent in writing to any discharge or compromise of any settlement or judgment of a lien created under RCW 42.20B.060. The department considers the compromise or discharge of a medical care lien only as authorized by federal regulation at 42 CFR 433.139.

(7) The doctrine of equitable subrogation does not apply to defeat, reduce, or prorate any recovery made by the department that is based on its assignment, lien, or subrogation rights.

[]

(1) ((The department shall provide medical care to)) An eligible Washington state resident((s in a)) may receive medical care in a recognized out-of-state bordering city on the same basis as in-state care.

(2) The only recognized bordering cities are:

(a) Coeur d'Alene, Moscow, Sandpoint, Priest River, and Lewiston, Idaho; and

(b) Portland, The Dalles, Hermiston, Hood River, Rainier, Milton-Freewater, and Astoria, Oregon.

[Statutory Authority: RCW 74.08.090.      94-10-065 (Order 3732), § 388-501-0175, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-82-130.]

(1) MAA requires a provider to seek timely reimbursement from a third party when a client has available third-party resources, except as described under subsections (2) and (3) of this section.

(2) MAA pays for medical services and seeks reimbursement from the liable third party when the claim is for any of the following:

(a) Prenatal care;

(b) Labor, delivery, and postpartum care (except inpatient hospital costs) for a pregnant woman; or

(c) Preventive pediatric services as covered under the EPSDT program.

(3) MAA pays for medical services and seeks reimbursement from any liable third party when both of the following apply:

(a) The provider submits to MAA documentation of billing the third party and the provider has not received payment after thirty days from the date of services; and

(b) The claim is for a covered service provided to a client on whose behalf the office of support enforcement is enforcing an absent parent to pay support. For the purpose of this section, "is enforcing" means the absent parent either:

(i) Is not complying with an existing court order; or

(ii) Received payment directly from the third party and did not pay for the medical

services.

(4) The provider may not bill MAA or the client for a covered service when a third party pays a provider the same amount as or more than the MAA rate.

(5) When the provider receives payment from the third party after receiving reimbursement from MAA, the provider must refund to MAA the amount of the:

(a) Third-party payment when the payment is less than MAA's maximum allowable rate; or

(b) MAA payment when the third-party payment is equal to or greater than MAA's maximum allowable rate.

(6) MAA is not responsible to pay for medical services when the third-party benefits are available to pay for the client's medical services at the time the provider bills MAA, except as described under subsections (2) and (3) of this section.

(7) The client is liable for charges for covered medical services that would be paid by the third party payment when the client either:

(a) Receives direct third-party reimbursement for such services; or

(b) Fails to execute legal signatures on insurance forms, billing documents, or other forms necessary to receive insurance payments for services rendered. See WAC 388-505-0540 for assignment of rights.

(8) MAA considers an adoptive family to be a third-party resource for the medical expenses of the birth mother and child only when there is a written contract between the adopting family and either the birth mother, the attorney, the provider, or the adoption service. The contract must specify that the adopting family will pay for the medical care associated with the pregnancy.

(9) A provider cannot refuse to furnish covered services to a client because of a third party's potential liability for the services.

(10) For third-party liability on personal injury litigation claims, MAA is responsible for providing medical services as described under WAC 388-87-020.

[]

(1) ((Pharmacies shall)) When billing for pharmacy services, providers must:

(a) Use the appropriate department claim form or electronic billing specifications ((when billing for pharmacy services)); and

(b) ((Complete such forms or billings before submitting claims to MAA.      Complete forms shall)) Include the actual eleven-digit NDC number of the product((s)) dispensed.

(2) ((To bill)) When billing drugs requiring authorization, providers ((shall)) must insert the authorization number in the appropriate data field ((of)) on the drug claim.

(3) ((To bill)) When billing drugs under the expedited authorization process, providers ((shall)) must insert the authorization number ((and)) which includes the corresponding criteria code((s)) in the appropriate data field ((of)) on the drug claim.

(4) Pharmacy services for clients on restriction under WAC 388-501-0135 ((shall)) must be prescribed by the client's primary care provider and ((payable)) are paid only to the client's primary pharmacy, except in cases of:

(a) Emergency((,));

(b) Family planning((, or)) services; or

(c) Services properly referred ((services)) from the client's assigned pharmacy or physician/ARNP.

[Statutory Authority: RCW 74.08.090.      96-21-031, § 388-530-1800, filed 10/9/96, effective 11/9/96.]

(1) The department ((shall)) reimburses out-of-state pharmacies for drugs provided to eligible MAA clients who are:

(a) Washington state residents ((who are)); and

(b) Located temporarily ((located)) outside the state subject to the provisions of WAC 388-501-0180.

(2) Border ((situations)) areas, as described under WAC 388-501-0175, are considered in-state and not subject to out-of-state rules((, and the department shall consider)). Pharmacies in border areas are eligible to apply to the department to be enrolled as providers of medical services in the state of Washington.

(3) Out-of-state pharmacies ((shall)) must meet the same criteria ((for payment)) as in-state pharmacies.

[Statutory Authority: RCW 74.08.090.      96-21-031, § 388-530-2050, filed 10/9/96, effective 11/9/96.]

(1) The medical assistance administration (MAA) pays school districts or educational service districts (ESD) for qualifying medical services provided to an eligible student. To be covered under this section, the student must be eligible for Title XIX (i.e., either the categorically needy or medically needy programs).

(2) To qualify for payment under this section, the medical services must be provided:

(a) By the school district or the ESD; and

(b) To the eligible special education student as part of the student's individualized education program (IEP) or individualized family service plan (IFSP).

(3) To qualify for payment under this section, the medical services must be provided by one of the following service providers:

(a) A qualified Medicaid provider as described under WAC 388-87-005;

(b) A psychologist, licensed by the state of Washington or granted an educational staff associate (ESA) certificate by the state board of education;

(c) A school guidance counselor, or a school social worker, who has been granted an ESA certificate by the state board of education; or

(d) A person trained and supervised by any of the following:

(i) A licensed registered nurse;

(ii) A licensed physical therapist or physiatrist;

(iii) A licensed occupational therapist; or

(iv) A speech pathologist or audiologist who:

(A) Has been granted a certificate of clinical competence by the American speech, hearing, and language association;

(B) Is a person who completed the equivalent educational and work experience necessary for such a certificate; or

(C) Is a person who has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

(4) Student service recommendations and referrals must be updated at least annually.

(5) The student does not need a provider prescription to receive services described under this section.

(6) MAA pays for school-based medical services according to the department-established rate or the billed amount, whichever is lower.

(7) MAA does not pay individual school practitioners who provide school-based medical services.

(8) For medical services billed to Medicaid, school districts or ESD, must pursue third-party resources.

[]

The department ((shall)) administers state funds ((appropriated)) to assist ((people with end stage renal disease to meet the costs of their)) eligible clients with medical care costs associated with end stage renal disease (ESRD).

[Statutory Authority: RCW 74.08.090.      93-16-039 (Order 3600), § 388-540-001, filed 7/28/93, effective 8/28/93.]

((For the purpose of administering the state kidney disease program (KDP),)) The following ((shall)) definitions and those found in WAC 388-500-0005, Medical definitions, apply((:)) to this chapter. Defined words and phrases are bolded in the text.

"Adequate consideration" means that the reasonable value of goods or services received in exchange for transferred property approximates the reasonable value of the property transferred;

"Affiliate" means a facility, hospital, unit, business, or person having an agreement with a kidney center to provide specified services to ESRD patients;

"Application for kidney disease program (KDP) eligibility" means the form provided by ((the department)) MAA, which the client completes and submits to the contracted kidney center to determine KDP eligibility;

"Assets" means income ((or)), resources, or any real or personal property that a person or the person's spouse owns and could convert to cash to be used for support or maintenance;

(("Break in service" means a previously certified client does not have medical coverage for a period of time when a new application for eligibility is submitted more than thirty days after the end of a previous certification period;))

"Certification" ((or "certified")) means the kidney center has determined a client eligible for the KDP for a defined period of time ((under this chapter));

(("Department" means the department of social and health services;))

"End stage renal disease (ESRD)" means that stage of renal impairment which is irreversible and permanent, and requires dialysis or kidney transplantation to ameliorate uremic symptoms and maintain life;

"KDP application period" means the time between the date of application and certification;

"KDP client" means a resident of the state ((with)) who has a diagnosis of ESRD and meets the financial and medical criteria to be determined eligible by a contracted kidney center;

"KDP contract manual" is a set of policies and procedures for contracting kidney centers;

"Kidney center" means ((those facilities)) a facility as defined and certified by the federal government to:

(1) Provide ESRD services ((and which));

(2) Provide the services specified in this chapter; and ((which))

(3) Promote and encourage home dialysis for a client when medically indicated;

"Kidney disease program (KDP)" is a public state program that helps eligible clients with the costs of ESRD-related medical care;

"Recertifying client" means a KDP client who was determined eligible the previous year for the KDP and will continue to qualify under this chapter;

(("Resident." Refer to WAC 388-505-0510;))

(("State kidney disease program (KDP)" means state general funds appropriated to the department to assist clients with ESRD in meeting the cost of medical care;))

"Substantial financial change" means:

(1) The elimination of a client's required annual deductible amount; or

(2) The increase or decrease of income or assets by fifteen hundred dollars.

(("Transfer" - Refer to WAC 388-500-0005;

"Value-fair market" - Refer to WAC 388-500-0005.))

[Statutory Authority: RCW 74.08.090, 74.04.005 and 74.08.025.      98-06-025, § 388-540-005, filed 2/24/98, effective 3/27/98.      Statutory Authority: RCW 74.08.090.      93-16-039 (Order 3600), § 388-540-005, filed 7/28/93, effective 8/28/93.]

((Generally,)) The kidney center ((shall)) must provide, directly or through an affiliate, all physical facilities, professional consultation, personal instructions, medical treatment and care, drug((s, dialysis equipment,)) products, and all supplies necessary for carrying out a medically-sound ESRD treatment program((.      The kidney center shall provide)), including all of the following:

(1) Dialysis for clients with ESRD when medically indicated;

(2) Kidney transplantation treatment, either directly or by referral, for clients with ESRD ((either directly or by referral,)) when medically indicated;

(3) Treatment for conditions directly related to ESRD;

(4) Training and supervision of ((medical,)) supporting personnel and ((of)) clients ((who are eligible)) for home dialysis, medical care, and treatment; and

(5) Supplies and equipment for home dialysis.

[Statutory Authority: RCW 74.08.090.      93-16-039 (Order 3600), § 388-540-010, filed 7/28/93, effective 8/28/93.]

((The department shall)) MAA reimburses kidney centers for services ((described in)) according to this chapter and the kidney center's contract with the department to the extent the legislature has appropriated funds ((and when the)).

(1) To request reimbursement, the kidney center must submit((s)) documented evidence, satisfactory to ((the department)) MAA, showing:

(((1))) (a) The services for which reimbursement is requested;

(((2))) and

(b) The client's financial eligibility for the state ((kidney disease program)) KDP under this chapter ((except reimbursement for services:

(a))).

(2) MAA limits reimbursement for services provided to a client ((location outside the)) while visiting out of state ((shall be limited to a period of two weeks)) to fourteen days per calendar year ((per client; and

(b) Described under this chapter shall be determined on a case-by-case basis by the department)).

[Statutory Authority: RCW 74.08.090.      93-16-039 (Order 3600), § 388-540-020, filed 7/28/93, effective 8/28/93.]

(1) ((A client is KDP eligible who meets the following requirements)) The kidney center determines clients' eligibility annually on a case-by-case basis, according to this chapter and the KDP contract manual. To be eligible for the KDP, a client must:

(a) ((Is)) Be a Washington state resident;

(b) ((Has)) Have countable resources, not exempted under subsection (2) of this section, which are equal to or lower than fifteen thousand dollars;

(c) ((Has)) Have countable income as defined ((under)) in WAC 388-500-0005, which is equal to or lower than three hundred percent of the federal poverty level (FPL); and

(d) Exhaust((s)) or ((is)) be ineligible for all other resources providing similar benefits to meet the cost of ESRD-related medical care, such as:

(i) Government or private disability programs; or

(ii) Local funds raised for the purpose of providing financial support for a specified ESRD client.

(2) The following resources are exempt:

(a) A home, defined as real property owned by a client as a principal place of residence, together with ((the)) surrounding and contiguous property ((surrounding and contiguous thereto,)) not to exceed five acres;

(b) Household furnishings; and

(c) An automobile.

[Statutory Authority: RCW 74.08.090, 74.04.005 and 74.08.025.      98-06-025, § 388-540-030, filed 2/24/98, effective 3/27/98.      Statutory Authority: RCW 74.08.090.      93-16-039 (Order 3600), § 388-540-030, filed 7/28/93, effective 8/28/93.]

A person may be ineligible for the ((program)) KDP if the person knowingly and willfully assigns or transfers nonexempt resources at less than fair market value within two years preceding the date of application, for the purpose of qualifying or continuing to qualify for the program ((within two years preceding the date of application)).

[Statutory Authority: RCW 74.08.090.      93-16-039 (Order 3600), § 388-540-040, filed 7/28/93, effective 8/28/93.]

The kidney center ((shall)) must provide fiscal information ((on the department's request.      The information shall include)) upon request by the department, including:

(1) Accounting information and documentation sufficient to establish the basis for fees for services and/or charges;

(2) Sources and amounts of resources allowing an individual client to verify financial eligibility;

(3) Evidence that all other available resources have been depleted before requests for reimbursement from the ((state kidney disease program)) KDP are submitted to ((the department)) MAA; and

(4) Other information as ((the department)) MAA may require.

[Statutory Authority: RCW 74.08.090.      93-16-039 (Order 3600), § 388-540-050, filed 7/28/93, effective 8/28/93.]

The ((department,)) kidney center and client ((shall)) must comply with the following rules to determine KDP eligibility:

(1) The kidney center ((shall)) must:

(a) Inform the client of the requirements for KDP eligibility as defined in this chapter;

(b) Provide the client with necessary department forms and instructions in a timely manner;

(c) Review the KDP application and documentation;

(d) Determine client eligibility using department policies, rules, and instructions; and

(e) Forward the KDP application and documentation to the medical assistance administration (MAA).      If necessary, ((the department)) MAA may amend or terminate a client's certification period within thirty days of receipt.

(2) A ((new client shall)) person applying for KDP must:

(a) Complete the KDP application and submit any documentation necessary ((documentation for)) to determine eligibility ((determination)) to the kidney center; and

(b) Apply for Medicaid, obtain a written Medicaid eligibility determination, and submit a copy to the kidney center.

(3) A ((recertifying)) client ((shall)) applying for recertification must:

(a) Apply for Medicaid forty-five days before the end of the KDP certification period((; and

(i))), obtain a written Medicaid eligibility determination((;)), and

(((ii))) submit a copy to the kidney center; or

(b) ((Be exempt from the requirement in (3)(a) of this subsection when the client has)) Have applied for Medicaid ((in the prior)) within the previous five years and ((will)) continue to be ineligible because the client:

(i) ((Be)) Was denied Medicaid due to:

(A) Failure to meet Medicaid categorical requirements;

(B) Assets ((exceeding)) which exceed Medicaid resource standards; or

(C) Income ((exceeding)) which exceeds the categorically needy income standards((.)); or

(ii) Does not meet the medically needy spenddown amount because the cost of medical care is:

(A) Less than the spenddown amount; or

(B) Covered by third-party insurance.

(4) The KDP application period is:

(a) One hundred and twenty days for a new client; and

(b) Forty-five days prior to the end of a certification period for a client requesting recertification.

(5) The kidney center may request an extension of application time limits from ((the department)) MAA when extenuating circumstances prevent the client from completing the application or recertification process within the specified time limits.

(6) The ((KDP)) kidney center certifies the client ((shall be certified)) as KDP eligible for a period of one year from the first day of the month of application, unless the client(('s)):

(a) ((Need for)) Needs medical coverage ((is)) for less than one year; or

(b) ((Assets change substantially)) Has a substantial financial change, in which case the client must complete a new application for KDP eligibility;

(7) The effective date of KDP eligibility ((effective date)) is the first day of the month of KDP application if the ((person)) client was eligible at any time during that month.      The effective date of KDP eligibility ((shall be no earlier than)) may be a maximum of four months before the month of KDP application ((provided)) if the:

(a) Medical services received were covered; and

(b) ((Person)) Client would have been eligible had the ((person)) client applied.

[Statutory Authority: RCW 74.08.090, 74.04.005 and 74.08.025.      98-06-025, § 388-540-060, filed 2/24/98, effective 3/27/98.      Statutory Authority: RCW 74.08.090.      93-16-039 (Order 3600), § 388-540-060, filed 7/28/93, effective 8/28/93.]

(1) The medical assistance administration (MAA) pays the provider of service in designated bordering cities as if the care were provided within the state of Washington (see WAC 388-501-0175). MAA requires providers to meet the licensing requirements of the state in which care is rendered.

(2) MAA does not authorize payment for out-of-state medical care furnished to clients in state-only funded medical programs.

(3) MAA applies the three-month retroactive coverage as defined under WAC 388-80-005 to covered medical services that are furnished to eligible clients by out-of-state providers.

(4) MAA requires out-of-state providers to obtain a valid provider number in order to be reimbursed.

(a) MAA requires a completed core provider agreement, and furnishes the necessary billing forms, instructions, and a core provider agreement to providers.

(b) MAA issues a provider number after receiving the signed core provider agreement.

(c) The billing requirements of WAC 388-87-010 and 388-87-015 apply to out-of-state providers.

(5) For Medicare-eligible clients, providers must submit Medicare claims, on the appropriate Medicare billing form, to the intermediary or carrier in the provider's state. If the provider checks the Medicare billing form to show the state of Washington as being responsible for medical billing, the intermediary or carrier may either:

(a) Forward the claim to MAA on behalf of the provider; or

(b) Return the claim to the provider, who then submits it to MAA.

(6) For covered services for eligible clients, MAA reimburses approved out-of-state nursing facilities at the lower of:

(a) The billed amount; or

(b) The adjusted statewide average reimbursement rate for in-state nursing facility care.

(7) For covered services for eligible clients, MAA reimburses approved out-of-state hospitals at the lower of:

(a) The billed amount; or

(b) The adjusted statewide average reimbursement rate for in-state hospitals.

(8) For covered services for eligible clients, MAA reimburses other approved out-of-state providers at the lower of:

(a) The billed amount; or

(b) The rate paid by the Washington state Title XIX Medicaid program.

[]

(1) ((The department shall assess interest on amounts of excess benefits or payments a certified provider of medical services receives:

(a) Who is found liable for receipt of excess payments under RCW 74.09.220;

(b) Otherwise served with notice that repayment of excess benefits is due under RCW 74.09.220; or

(c) Except for nursing homes which are governed by WAC 388-96-310.

(2) Under RCW 74.09.220, the department shall assess interest on excess benefits or payments at the rate of one percent each month from the date upon which payment was made to the date upon which repayment is made to the state.      Interest does not apply when the excess benefits or payments were obtained as a result of errors made by the department.

(3) The department shall ensure:

(a) Interest amounts will be clearly identified in all overpayment communications; and

(b) A daily interest accrual amount will be identified and accrued until the day immediately preceding the day the full repayment check is mailed to the state.

(4) When repayment is made through the recoupment process (payments are withheld from current bills until the overpayment amount is met), the department shall ensure interest accrues to the date recoupment is finalized)) Providers who are enrolled as contractors with the department's medical care programs may be assessed interest on excess benefits or other inappropriate payments. Nursing home providers are governed by WAC 388-96-310 and are not subject to this section.

(2) The department assesses interest when:

(a) The excess benefits or other inappropriate payments were not the result of department error; and

(b) A provider is found liable for receipt of excess benefits or other payments under RCW 74.09.220; or

(c) A provider is notified by the department that repayment of excess benefits or other payments is due under RCW 74.09.220.

(3) The department assesses interest at the rate of one percent for each month the overpayment is not satisfied. Daily interest calculations and assessments are made for partial months.

(4) Interest is calculated beginning from the date the department receives payment from the provider. Interest ceases to be calculated and collected from the provider once the overpayment amount is received by the department.

(5) The department calculates interest and amounts, which are identified on all department collection notices and statements.

[Statutory Authority: RCW 74.08.090.      94-10-065 (Order 3732), § 388-502-0250, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-81-044.]

The following section of the Washington Administrative Code, as amended, is recodified as follows:

Old WAC Number	New WAC Number
388-502-0250	388-502-0130

2600.1
REPEALER

     The following section of the Washington Administrative Code is repealed:

WAC 388-86-022

School medical services for special education students.

2601.2
REPEALER

     The following sections of the Washington Administrative Code are repealed:

WAC 388-87-020	Subrogation.
WAC 388-87-025	Services requiring approval.
WAC 388-87-105	Payment -- Medical care outside state of Washington.
WAC 388-87-250	Third-party resources.

© Washington State Code Reviser's Office