WSR 02-09-079

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed April 17, 2002, 8:38 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 02-01-076.

Title of Rule: WAC 388-502-0160 Billing a client.

Purpose: To discourage clients from seeking treatment for nonemergency medical conditions at hospital emergency rooms when less costly alternatives, e.g., doctor's office or medical clinic, are available.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.055, ESSB 6153 - Washington State Omnibus Operating Budget 2001-2003 (chapter 7, Part II, Laws of 2001).

Statute Being Implemented: ESSB 6153 - Washington State Omnibus Operating Budget 2001-2003 (chapter 7, Part II, Laws of 2001).

Summary: This rule amendment will allow hospitals to impose a $3 copayment on a MAA client who is treated in a hospital emergency room for a nonemergency condition when other reasonable alternatives (e.g., doctor's office, medical clinic) are available to the client. Clients who are indigent, eighteen years of age and under, pregnant, American Indian or Alaskan Native, enrolled in a MAA managed care plan, or receiving long-term care services will be exempt from the copayment requirement.

Reasons Supporting Proposal: It is more cost effective to treat clients in a clinic or doctor's office that in a hospital emergency room.

Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1344; Implementation and Enforcement: Judy Maginnis, P.O. Box 45534, Olympia, WA 98504-5534, (360) 725-1320.

Name of Proponent: Department of Social and Health Services, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: This rule amendment will allow hospitals to impose a $3 copayment on a MAA client who is treated in a hospital emergency room for a nonemergency condition when other reasonable alternatives (e.g., doctor's office, medical clinic) are available to the client. Clients who are indigent, eighteen years of age and under, pregnant, American Indian or Alaskan Native, enrolled in a MAA managed care plan, or receiving long-term care services will be exempt from the copayment requirement.

The purpose of this rule is to discourage clients from seeking treatment for nonemergency medical conditions at hospital emergency rooms when less costly alternatives, e.g., doctor's office or medical clinics, are available.

It is anticipated that this rule amendment will result in fewer clients using hospital emergency rooms for treatment of nonemergency conditions.

Proposal Changes the Following Existing Rules: This rule amendment will allow hospitals to impose a $3 copayment on a MAA client who is treated in a hospital emergency room for a nonemergency condition when other reasonable alternatives (e.g., doctor's office, medical clinic) are available to the client.

No small business economic impact statement has been prepared under chapter 19.85 RCW. This amendment will not place more than a minor economic impact on small businesses.

RCW 34.05.328 applies to this rule adoption. The department has analyzed the proposed rule and determined that it meets the definition of a "significant legislative rule." A determination of the probable costs and benefits is available from the person listed above.

Hearing Location: Office Building-2 Auditorium (DSHS Headquarters) (parking available on 12th off Jefferson), 1115 Washington, Olympia, WA 98504, on May 21, 2002, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by May 17, 2002, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5 p.m., May 21, 2002.

Date of Intended Adoption: Not sooner than May 22, 2002.

April 11, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3060.2
AMENDATORY SECTION(Amending WSR 01-21-023, filed 10/8/01, effective 11/8/01)

WAC 388-502-0160   Billing a client.   (1) A provider may not bill, demand, collect, or accept payment from a client or anyone on the client's behalf for a covered service. The client is not responsible to pay for a covered service even if MAA does not pay the provider because the provider failed to satisfy the conditions of payment in MAA billing instructions, this chapter, and other chapters regulating the specific type of service provided.

(2) The provider is responsible for verifying whether the client has medical coverage for the date of service and to check the limitations of the client's medical program.

(3) A provider may bill a client only if one of the following situations apply:

(a) The client is enrolled in medical assistance managed care and the client and provider comply with the requirements in WAC 388-538-095;

(b) The client is not enrolled in medical assistance managed care, and the client and provider sign an agreement regarding payment for the service. The agreement must be translated or interpreted into the client's primary language and signed before the service is rendered. The provider must give the client a copy and maintain the original in the client's file for department review upon request. The agreement must include each of the following elements to be valid:

(i) A statement listing the specific service to be provided;

(ii) A statement that the service is not covered by MAA;

(iii) A statement that the client chooses to receive and pay for the specific service; and

(iv) The client is not obligated to pay for the service if it is later found that the service was covered by MAA at the time it was provided, even if MAA did not pay the provider for the service because the provider did not satisfy MAA's billing requirements.

(c) The client or the client's legal guardian was reimbursed for the service directly by a third party (see WAC 388-501-0200);

(d) The client refuses to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill insurance for the service. This provision does not apply to coverage provided by MAA;

(e) The provider has documentation that the client represented himself/herself as a private pay client and not receiving medical assistance when the client was already eligible for and receiving benefits under a MAA medical program. This documentation must be signed and dated by the client or the client's representative. The provider must give a copy to the client and maintain the original documentation in the client's file for department review upon request. In this case, the provider may bill the client without fulfilling the requirements in subsection (3)(b) of this section regarding the agreement to pay. However, if the patient later becomes eligible for MAA coverage of a provided service, the provider must comply with subsection (4) of this section for that service; ((or))

(f) The bill counts toward a spenddown liability, emergency medical expense requirement, deductible, or copayment required by MAA; or

(g) The client received medical services in a hospital emergency room for a condition that was not an emergency medical condition. In such cases, a three-dollar copayment may be imposed on the client by the hospital, except when:

(i) Reasonable alternative access to care was not available;

(ii) The "indigent person" criteria in WAC 246-453-040(1) applies;

(iii) The client was eighteen years of age or younger;

(iv) The client was pregnant or within sixty days postpregnancy;

(v) The client is an American Indian or Alaska Native;

(vi) The client was enrolled in a MAA managed care plan, including primary care case management (PCCM);

(vii) The client was in an institution such as a nursing facility or residing in an alternative living facility such as an adult family home, assisted living facility, or boarding home; or

(viii) The client receives waivered services such as community options program entry system (COPES) and community alternatives program (CAP).

(4) If a client becomes eligible for a covered service that has already been provided because the client:

(a) Applied to the department for medical services later in the same month the service was provided (and is made eligible from the first day of the month), the provider must:

(i) Not bill, demand, collect, or accept payment from the client or anyone on the client's behalf for the service; and

(ii) Promptly refund the total payment received from the client or anyone on the client's behalf, and then bill MAA for the service;

(b) Receives a delayed certification as defined in WAC 388-500-0005, the provider must:

(i) Not bill, demand, collect, or accept payment from the client or anyone on the client's behalf for the service; and

(ii) Promptly refund the total payment received from the client or anyone on the client's behalf, and then bill MAA for the service; or

(c) Receives a retroactive certification as defined in WAC 388-500-0005, the provider:

(i) Must not bill, demand, collect, or accept payment from the client or anyone on the client's behalf for any unpaid charges for the service; and

(ii) May refund any payment received from the client or anyone on the client's behalf, and after refunding the payment, the provider may bill MAA for the service.

(5) Hospitals may not bill, demand, collect, or accept payment from a medically indigent, GA-U, or ADATSA client, or anyone on the client's behalf, for inpatient or outpatient hospital services during a period of eligibility, except for spenddown and under the circumstance described in subsection (3)(g) of this section.

(6) A provider may not bill, demand, collect, or accept payment from a client, anyone on the client's behalf, or MAA for copying or otherwise transferring health care information, as that term is defined in chapter 70.02 RCW, to another health care provider. This includes, but is not limited to:

(a) Medical charts;

(b) Radiological or imaging films; and

(c) Laboratory or other diagnostic test results.

[Statutory Authority: RCW 74.08.090. 01-21-023, 388-502-0160, filed 10/8/01, effective 11/8/01; 01-05-100, 388-502-0160, filed 2/20/01, effective 3/23/01. Statutory Authority: RCW 74.08.090 and 74.09.520. 00-14-069, 388-502-0160, filed 7/5/00, effective 8/5/00.]

Washington State Code Reviser's Office