WSR 00-19-117

PERMANENT RULES

DEPARTMENT OF HEALTH


[ Filed September 20, 2000, 11:59 a.m. ]

Date of Adoption: August 30, 2000.

Purpose: The HIV early intervention program helps eligible persons with HIV infection in Washington state pay for prescription medications and other services to treat HIV infection. Chapter 246-130 WAC identifies the services the program offers, how the department decides what services to offer, how clients may access the services, how providers are reimbursed, and how the public may provide input.

Citation of Existing Rules Affected by this Order: Repealing WAC 246-130-070; and amending WAC 246-130-001, 246-130-010, 246-130-020, 246-130-030, 246-130-040, and 246-130-060.

Statutory Authority for Adoption: RCW 43.70.040.

Other Authority: RCW 43.70.120.

Adopted under notice filed as WSR 00-14-063 on July 5, 2000.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 3, Amended 6, Repealed 1.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 6, Repealed 1.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 6, Repealed 1. Effective Date of Rule: Thirty-one days after filing.

September 19, 2000

M. C. Selecky

Secretary

OTS-4195.2


AMENDATORY SECTION(Amending WSR 95-23-018, filed 11/7/95, effective 12/8/95)

WAC 246-130-001
((Purpose.)) What is the HIV early intervention program?

((The department shall administer federal and state funds appropriated to assist eligible persons with HIV infection to access early intervention services.)) The early intervention program provides treatment of HIV infection to eligible clients based on available funds. The department provides these early intervention services to improve the public health by treating people living with HIV, its complications, and side effects of HIV treatment, and in order to decrease the risk of clients with HIV infecting others. Information on how to contact this program is in WAC 246-130-090.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 95-23-018, 246-130-001, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as 246-130-001, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), 248-168-010, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), 248-168-010, filed 10/26/87.]


AMENDATORY SECTION(Amending WSR 95-23-018, filed 11/7/95, effective 12/8/95)

WAC 246-130-010
((Definitions.)) What definitions do we use?

The following words and phrases have the following meaning in chapter 246-130 WAC ((unless the context clearly indicates otherwise)):

(("AIDS" means acquired immunodeficiency syndrome.

"APDP" means HIV/AIDS prescription drug program.

"Department" or "DOH" means the Washington state department of health.

"Early intervention services" means personal health services and behavioral risk reduction interventions codelivered with these services that reduce the rate of progression of HIV infection and reduce HIV transmission.

"HIP" means the HIV intervention program.

"HIV" means human immunodeficiency virus.

"Participation" means the amount of cost borne by the eligible client.

"Personal health services" mean clinical interventions and treatments, including but not limited to medications, that are delivered to individuals and are intended to reduce morbidity and mortality.)) (1) "AIDS" means acquired immunodeficiency syndrome.

(2) "Applicant" means a person applying for early intervention program services.

(3) "Client" means a person determined to be currently eligible by the department for early intervention program services.

(4) "Department" means the Washington state department of health.

(5) "Early intervention program services" means medically necessary treatment and services that reduce the rate of progression of HIV infection and HIV transmission. This includes behavioral risk reduction interventions. See WAC 246-130-020 for details.

(6) "Federal poverty level" means the official income level for poverty released by the federal government each year in February.

(7) "Formulary" means the list of prescription drugs that the early intervention program will pay for. To obtain a copy of that list, see WAC 246-130-090.

(8) "HIV" means human immunodeficiency virus.

(9) "Medical assistance administration (MAA)" means the part of the department of social and health services responsible for operating the state's Medicaid and related medical programs.

(10) "Provider" means a health care professional contracted by the department to supply pharmaceutical, medical, dental, or laboratory services to a client.

(11) "Schedule of services" means the department's list of medical, dental, and laboratory services covered by its early intervention program. To obtain a copy of that list, see WAC 246-130-090.

(12) "Standard of care" means treatment for HIV commonly accepted by the local medical community.

(13) "Steering committee" means the department's HIV early intervention steering committee. This advisory committee serves at the pleasure of the DOH secretary per RCW 43.70.040(2), consists of Washington state residents living with HIV and HIV medical experts and community organizations, and advises the department on its early intervention program. Its bylaws are available from the department per WAC 246-130-090.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 95-23-018, 246-130-010, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), 246-130-010, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as 246-130-010, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), 248-168-015, filed 8/17/90, effective 9/17/90.]


AMENDATORY SECTION(Amending WSR 95-23-018, filed 11/7/95, effective 12/8/95)

WAC 246-130-020
((Early intervention services.)) What early intervention program services are available?

((To the extent federal or state funds are appropriated for the purpose of providing services through HIP or APDP, the department shall contract with participating pharmacies, other health care providers, or social service providers for the delivery of early intervention services.)) Services to treat HIV are available from the department, based on available funding, to eligible clients as described in this section.

(1) The department decides what specific medical, laboratory, dental, and prescription medication services to cover after actively consulting with its steering committee and considering:

(a) Support of the steering committee, which represents clients and local medical HIV/AIDS communities;

(b) FDA approval (for prescription medications);

(c) Recognition by the medical community as a standard of care;

(d) Effectiveness in treatment for HIV, complications of HIV, side effects of current treatments for HIV or support for HIV treatment adherence; and

(e) Relative cost of services.

(2) The early intervention program services described in this section are available to all clients, unless they receive those services from other sources. Specific services of this section are available for a client only when medically necessary to treat HIV and associated diseases, complications of treating HIV, or support for HIV treatment adherence.

(3) Specific covered medical, laboratory, and dental services are listed in the department's "schedule of services."

(4) Prescription drugs covered are listed in the department's "early intervention drug formulary."

(5) Covered health insurance includes:

(a) Premium payment, including COBRA premiums;

(b) Deductible payment up to five hundred dollars per twelve-month period; and

(c) Co-pay payment for third-party insurance, except basic health plan, as follows:

(i) The percentage of prescription medication costs covered by the department and not covered by third-party insurers; and

(ii) Fixed dollar co-pay required by a client's third-party insurance plan.

(d) For basic health plan enrollees, the department pays the percentage of prescription medication expenses not covered by the basic health plan but covered by the department's early intervention program formulary.

(6) The department may also coordinate other services to treat HIV and AIDS. These are available as funding and contracting permit. For example, as of July 1, 2000, the department may pay the spend-down for MAA medically needy (MN) clients who are also DOH clients, up to one thousand one hundred dollars per month.

(7) You may contact the department per WAC 246-130-090 to make comments on service coverage or to receive information.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 95-23-018, 246-130-020, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as 246-130-020, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), 248-168-020, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), 248-168-020, filed 10/26/87.]


NEW SECTION
WAC 246-130-028
What services are not available?

The department does not cover any services which are:

(1) Not specified or referenced in WAC 246-130-020; or

(2) Not funded as specified in WAC 246-130-030(3).

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AMENDATORY SECTION(Amending WSR 95-23-018, filed 11/7/95, effective 12/8/95)

WAC 246-130-030
((Reimbursements.)) How do we pay providers?

((The department will make reimbursement to contracted providers to provide early intervention services to eligible persons. The department shall produce a schedule of reimbursement for all services covered on a fee-for-service basis that shall be applicable to all contracted providers.)) The department pays providers for covered services delivered to clients, as limited by this section.

(1) The department pays providers who contract with the department for services described in WAC 246-130-020.

(a) The department will only pay for services delivered by a contracted provider.

(b) Services must be billed within one hundred eighty days of being provided.

(2) The department only pays for covered, medically necessary early intervention program services delivered to clients who are eligible under WAC 246-130-040.

(3) Payment of services depends on availability of federal and state funds. The department will not deny payment of any individual claim for funding availability unless the department denies an entire class of claims, or an entire program.

(a) Providers and clients will receive written notice of any limitation or reduction in coverage or payment that results from loss of federal or state funding at least thirty days in advance.

(b) If the department denies or reduces payment for any class of claims or program, it must only show that it made a good faith effort to mail written notice to all providers and clients.

(4) Providers who dispute a payment may do so through the contracts process. See WAC 246-130-080(3).

(5) Providers must bill the department per terms of the contract between the provider and department.

(6) The department is payer of last resort.

(a) Providers must bill all other third-party sources prior to billing the department for covered services, and

(b) Providers must reimburse the department for any funds paid by the department, which are payable by other sources.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 95-23-018, 246-130-030, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), 246-130-030, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as 246-130-030, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), 248-168-030, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), 248-168-030, filed 10/26/87.]


AMENDATORY SECTION(Amending WSR 95-23-018, filed 11/7/95, effective 12/8/95)

WAC 246-130-040
((Financial eligibility.)) How do persons with HIV become eligible?

((The department shall provide early intervention services for persons with HIV infection, including those persons with disabling AIDS conditions, who meet financial eligibility requirements established by the department and who are not receiving similar services funded by other resources. Prior to their application, the department shall publish and seek public comment upon the process and criteria for establishing medical and financial eligibility for early intervention services. The department shall provide for public involvement in establishing and periodically reviewing these criteria, including seeking input from clients and providers of early intervention services.

The following exemptions shall not be considered in determining financial eligibility for early intervention services:

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

(2) Commercial property, or property used for the purpose of producing income, except to the extent that its value exceeds the sum of twenty thousand dollars;

(3) Household furnishings;

(4) An automobile;

(5) Savings, property, or other liquid assets, to the extent the value thereof does not exceed the sum of ten thousand dollars;

(6) Proceeds whether lump sum or annuities from a viatical settlement contract; and

(7) Accelerated benefits of a life insurance policy whether in lump sum or annuities.)) (1) The department determines client eligibility for its early intervention program per this section. Beginning the month that the applicant's completed application was postmarked, an applicant is eligible for twelve months of early intervention program services when:

(a) The applicant has a medical diagnosis of HIV (the department may require a doctor's diagnosis);

(b) The applicant has a Washington state address and intends to stay in Washington state;

(c) The applicant or his/her designated representative has submitted truthful information on the department's application form to the department;

(d) The applicant has monthly income, averaged over twelve months, equal to or less than the limit set by DOH in consultation with the early intervention program steering committee. For example: In 2000, that limit was three hundred seventy percent of Federal Poverty Level for one person ($2,575) per month. The department shall announce and seek public comment on proposed changes to the income limit. Income includes:

(i) Wages, salary, overtime, tips, and bonuses;

(ii) Social Security, trust funds for disability, or other disability insurance payments;

(iii) Unemployment benefits;

(iv) Veteran's Administration benefits;

(v) Lump sum payments of gifts, cash inheritance, property, lottery winnings, worker's compensation for lost income, or severance pay;

(vi) Private pensions, annuities, or royalties; and

(vii) Investment dividends.

(e) The applicant has current resources of less than ten thousand dollars. Resources include trust funds, and any other financial resources available to the applicant. The department does not count the following as resources:

(i) One home, defined as real property owned by the client as his or her principal place of residence in Washington state, together with surrounding property not to exceed five acres;

(ii) Commercial property, or property used for producing income, up to the first twenty thousand dollars of value;

(iii) Household furnishings;

(iv) One automobile; or

(v) Pensions and other Internal Revenue Service designated retirement accounts;

(f) The applicant is not currently eligible for or cannot access medical benefits from the department of social and health services; and

(g) The applicant is not currently an inmate of any correctional institute or jail or will not be when their application is approved.

(2) Periods of eligibility caused by false information may cause the department to:

(a) Disenroll a client from the department's early intervention program; and

(b) Recover funds paid by the department during periods of false eligibility.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 95-23-018, 246-130-040, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), 246-130-040, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as 246-130-040, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), 248-168-040, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), 248-168-040, filed 10/26/87.]


AMENDATORY SECTION(Amending WSR 95-23-018, filed 11/7/95, effective 12/8/95)

WAC 246-130-060
((Medical and financial information.)) What information is required for client eligibility, and will it be kept confidential?

((An individual seeking early intervention services shall provide medical and financial information upon request of the department including:

(1) Sources and amounts of resources to verify financial eligibility;

(2) Evidence that all other available resources or entitlements for which a person is eligible were accessed before a person could receive early intervention services through HIP or APDP; and

(3) Other medical or financial information as required by the department.)) An applicant seeking early intervention program services must apply to the department.

(1) Applicant and client information supplied to the department is confidential.

(2) Applicants must provide medical and financial information at the department's request, including:

(a) Sources and amounts of all income and resources;

(b) Evidence that all resources or entitlements available to an applicant were accessed before that applicant applied for or received early intervention program services; and

(c) Other medical or financial information.

(3) Clients must notify the department of medical or financial changes that affect their eligibility within twenty days of the change. Clients who do not notify the department of medical or financial changes must pay back to the department funds provided during the period of ineligibility caused by those changes.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 95-23-018, 246-130-060, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as 246-130-060, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), 248-168-060, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), 248-168-060, filed 10/26/87.]


NEW SECTION
WAC 246-130-080
What do clients do if they disagree with the department's decision about their eligibility or coverage?

Applicants and clients may appeal any decision by the department about their early intervention program eligibility or coverage.

(1) Chapter 246-10 WAC details the adjudicated proceeding for matters involving receipt of benefits. The department will provide information on the cause for denied benefits, how a proceeding may be requested, the forms necessary to request a proceeding and information on required time frames.

(2) Applicants and clients may not appeal the department's denial or limitations when the department closes or limits an early intervention program service due to funding availability. See WAC 246-130-030(3) for more details.

(3) Rate and payment disputes between providers and the department are handled by contract.

(4) Clients of any other public agency must use that agency's process to resolve eligibility or other disputes regarding that agency. MAA's fair hearings process is described in chapter 388-08 WAC.

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NEW SECTION
WAC 246-130-090
How do I contact the department?

For information or application, contact:


Department of Health

Client Services

P.O. Box 47841

Olympia, WA 98504-7841

Telephone 1-800-272-2437 Option 2


Or, visit the WEB site at www.doh.wa.gov. Clicking on "HIV Information" accesses information about the early intervention program.

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REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 246-130-070 Participation.

Washington State Code Reviser's Office