WSR 02-10-113

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed April 30, 2002, 4:33 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 01-11-096.

Title of Rule: New WAC 388-550-2565 The long term acute care (LTAC) program -- General, 388-550-2570 LTAC Program definitions, 388-550-2575 Client eligibility requirements for LTAC services, 388-550-2580 Requirements for becoming an LTAC facility, 388-550-2585 LTAC facilities -- Quality of care, 388-550-2590 MAA's prior authorization requirements for Level 1 and Level 2 services, 388-550-2595 Identification of and payment methodology for services and equipment included in the LTAC fixed per diem rate, and 388-550-2596 Services and equipment covered by MAA but not included in the LTAC fixed per diem rate.

Purpose: To incorporate into rule the long term acute care (LTAC) program.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090.

Summary: The rules describe MAA's LTAC program that provides LTAC Level 1 or Level 2 services in an MAA-approved LTAC facility to an MAA client during the acute phase of the client's care. The rule also states requirements for client eligibility, MAA-approved facilities (including quality of care), and prior authorization. In addition, the rule clarifies terms used in the program. Payment methodology is described for services and equipment included in the LTAC fixed per diem rate, and for services and equipment covered by MAA but not included in the LTAC fixed per diem rate.

Reasons Supporting Proposal: State plan amendment, centers for Medicare and Medicaid services (CMS) will authorize a federal match when the pilot project is converted to a standard program.

Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 5533, Olympia, WA 98504, (360) 725-1342; Implementation and Enforcement: Larry Linn, P.O. Box 5510, Olympia, WA 98504, (360) 725-1856.

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: The new rule incorporates into rule MAA's LTAC program, clarifies and defines terms used in the program, and describes LTAC facility requirements, including quality of care. It also describes client eligibility, prior authorization requirements, and payment methodology. The purpose of the rule is to provide a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services to clients in an MAA-approved LTAC facility. Its anticipated effect is to provide such services at a reduced rate reimbursement to the LTAC facility after the cost of client services has reached the high cost outlier status under the diagnostic reimbursement group (DRG) payment method at the transferring hospital.

Proposal does not change existing rules.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule and concludes that it will have no more than minor impact upon affected businesses. For approximately five years, the LTAC program has been in pilot project status. During this time, it has demonstrated to be an economical and desirable program for both the transferring and LTAC hospitals and, in addition, has provided a continuum of quality client care. MAA is simply converting the program to permanent program status now that it has been approved in the Medicaid state plan.

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 entrance at 12th and Washington), 1115 Washington, Olympia, WA, on June 4, 2002, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by May 31, 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 5:00 p.m., June 4, 2002.

Date of Intended Adoption: Not sooner than June 5, 2002.

April 25, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3015.5
NEW SECTION
WAC 388-550-2565   The long term acute care (LTAC) program -- General.   The long term acute care (LTAC) program is a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services provided in a medical assistance administration (MAA)-approved LTAC facility during the acute phase of a client's care. MAA requires prior authorization for LTAC stays. See WAC 388-550-2590 for prior authorization requirements.

(1) A facility's multidisciplinary team coordinates individualized LTAC services at an MAA-approved LTAC facility.

(2) MAA determines the authorized length of stay for LTAC services based on the client's need as documented in the client's medical records and the criteria described in WAC 388-550-2590.

(3) When the MAA-authorized length of stay ends, the provider transfers the client to a more appropriate level of care or, if appropriate, discharges the client to the client's residence.

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NEW SECTION
WAC 388-550-2570   LTAC program definitions.   The following definitions and abbreviations and those found in WAC 388-500-0005 and 388-550-1050 apply to the LTAC program.

"Level 1 services" means long term acute care (LTAC) services provided to clients who require more than eight hours of direct skilled nursing care per day. Level 1 services include one or both of the following:

(1) Active ventilator weaning care and any specialized therapy services, such as physical, occupational, and speech therapies; or

(2) Complex medical care that may include: Care for complex draining wounds, care for central lines, multiple medications, frequent assessments and close monitoring, third degree burns that may involve grafts and/or frequent transfusions, and specialized therapy services, such as physical, occupational, and speech therapies.

"Level 2 services" means long term acute care (LTAC) services provided to clients who require four to eight hours of direct skilled nursing care per day. Level 2 services include at least two of the following:

(1) Ventilator care for clients who are stable, dependent on a ventilator, and have complex medical needs;

(2) Care for clients who have tracheostomies, complex airway management and medical needs, and the potential for decannulation; and

(3) Specialized therapy services, such as physical, occupational, and speech therapies.

"Long term acute care" means inpatient intensive long term care services provided in MAA-approved LTAC facilities to eligible medical assistance clients who require Level 1 or Level 2 services.

"Survey" or "review" means an inspection conducted by a federal, state, or private agency to evaluate and monitor a facility's compliance with LTAC program requirements.

"Transportation company" means either an MAA-approved transportation broker or a transportation company doing business with MAA.

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NEW SECTION
WAC 388-550-2575   Client eligibility requirements for LTAC services.   Only a client who is eligible for one of the following programs may receive LTAC services, subject to the restrictions and limitations in WAC 388-550-2565, 388-550-2570, 388-550-2580, 388-550-2585, 388-550-2590, 388-550-2595, 388-550-2596, and other published rules:

(1) Categorically needy program (CNP);

(2) CNP - Children's health insurance program (CNP-CHIP);

(3) Limited casualty program - medically needy program (LCP-MNP);

(4) CNP - Emergency medical only; or

(5) LCP-MNP - Emergency medical only.

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NEW SECTION
WAC 388-550-2580   Requirements for becoming an LTAC facility.   (1) To apply to become an MAA-approved LTAC facility, MAA requires a hospital provider to:

(a) Submit a letter of request to:

LTAC Program Manager

Division of Medical Management

Medical Assistance Administration

PO Box 45506

Olympia WA 98504-5506; and

(b) Include documentation that confirms the facility is:

(i) Medicare certified for LTAC;

(ii) Accredited by the joint commission on accreditation of hospital organizations (JCAHO);

(iii) Licensed by the department of health (DOH) as an acute care hospital as defined under WAC 246-310-010; and

(iv) Contracted under MAA's selective contracting program, if in a selective contracting area, unless exempted from the requirements by MAA.

(2) The hospital facility qualifies as an MAA-approved LTAC facility when:

(a) The facility meets all the requirements in this section;

(b) MAA's clinical staff has conducted a facility site visit; and

(c) MAA provides written notification that the facility qualifies to be reimbursed for providing LTAC services to eligible medical assistance clients.

(3) MAA-approved LTAC facilities must meet the general requirements in chapter 388-502 WAC, Administration of medical programs Providers.

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NEW SECTION
WAC 388-550-2585   LTAC facilities -- Quality of care.   (1) To ensure quality of care, MAA may conduct post-pay or on-site reviews of any MAA-approved LTAC facility. See WAC 388-502-0240, Audits and the audit appeal process for contractors/providers, for additional information on audits conducted by department staff.

(2) A provider of LTAC services must act on any reports of substandard care or violations of the facility's medical staff bylaws. The provider must have and follow written procedures that provide a resolution to either a complaint or grievance or both.

(3) A complaint or grievance regarding substandard conditions or care may be investigated by any one or more of the following:

(a) The department of health (DOH);

(b) The Joint Commission on Accreditation of Hospital Organizations (JCAHO);

(c) MAA; or

(d) Other agencies with review authority for MAA programs.

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NEW SECTION
WAC 388-550-2590   MAA's prior authorization requirements for Level 1 and Level 2 services.   (1) MAA requires prior authorization for Level 1 and Level 2 LTAC inpatient stays. The prior authorization process includes all of the following:

(a) For an initial thirty-day stay:

(i) The client must:

(A) Be eligible under one of the programs listed in WAC 388-550-2575;

(B) Meet the high cost outlier status at the transferring hospital as described in WAC 388-550-3700; and

(C) Require Level 1 or Level 2 services as defined in WAC 388-550-2570.

(ii) The LTAC provider of services must:

(A) Before admitting the client to the LTAC facility, submit a request for prior authorization to the MAA clinical consultation team by fax, electronic mail, or telephone, as published in MAA's LTAC billing instructions; and

(B) Include sufficient medical information to justify the requested initial stay.

(b) For extensions of stay:

(i) The client must:

(A) Be eligible under one of the programs listed in WAC 388-550-2575; and

(B) Require Level 1 or Level 2 services as defined in WAC 388-550-2570.

(ii) The LTAC provider of services must:

(A) Before the client's current authorized period of stay expires, submit a request for the extension of stay to the MAA clinical consultation team by fax, electronic mail, or telephone; and

(B) Include sufficient medical information to justify the requested extension of stay.

(2) The MAA clinical consultation team authorizes, in writing, Level 1 or Level 2 services for initial stays or extensions of stay based on the client's circumstances and the medical justification received. A client who does not agree with a decision regarding a length of stay has a right to a fair hearing under chapter 388-02 WAC. After receiving a request for a fair hearing, MAA may request additional information from the client and the facility, or both. After MAA reviews the available information, the result may be:

(a) A reversal of the initial MAA decision;

(b) Resolution of the client's issue(s); or

(c) A fair hearing conducted per chapter 388-02 WAC.

(3) MAA may authorize administrative day rate reimbursement for a client who:

(a) Does not meet the requirements described in this section;

(b) Is waiting for placement in another facility; or

(c) If appropriate, is waiting to be discharged to the client's residence.

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NEW SECTION
WAC 388-550-2595   Identification of and payment methodology for services and equipment included in the LTAC fixed per diem rate.   (1) In addition to room and board, the LTAC fixed per diem rate includes, but is not limited to, the following (see MAA's LTAC billing instructions for applicable revenue codes):

(a) Room and board - Rehabilitation;

(b) Room and board - Intensive care;

(c) Medical/surgical supplies and devices;

(d) Laboratory - General;

(e) Laboratory - Chemistry;

(f) Laboratory - Immunology;

(g) Laboratory - Hematology;

(h) Laboratory - Bacteriology and microbiology;

(i) Laboratory - Urology;

(j) Laboratory - Other laboratory services;

(k) Respiratory services;

(l) Physical therapy;

(m) Occupational therapy; and

(n) Speech-language therapy.

(2) MAA pays the LTAC facility the LTAC fixed per diem rate in effect at the time the LTAC services are provided, minus the sum of:

(a) Client liability, whether or not collected by the provider; and

(b) Any amount of coverage from third parties, whether or not collected by the provider, including, but not limited to, coverage from:

(i) Insurers and indemnitors;

(ii) Other federal or state medical care programs;

(iii) Payments made to the provider on behalf of the client by individuals or organizations not liable for the client's financial obligations; and

(iv) Any other contractual or legal entitlement of the client, including, but not limited to:

(A) Crime victims' compensation;

(B) Workers' compensation;

(C) Individual or group insurance;

(D) Court-ordered dependent support arrangements; and

(D) The tort liability of any third party.

(3) MAA may make annual rate increases to the LTAC fixed per diem rate by using the same inflation factor and date of rate increase that MAA uses for acute care hospital diagnostic-related group (DRG) rates. This DRG rate adjustment method is described in WAC 388-550-3450(5).

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Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 388-550-2596   Services and equipment covered by MAA but not included in the LTAC fixed per diem rate.   (1) MAA uses the ratio of costs-to-charges (RCC) payment method to reimburse an LTAC facility for the following that are not included in the LTAC fixed per diem rate:

(a) Prescription drugs;

(b) Total parenteral nutrition (TPN) therapy;

(c) Epogen/neupogen therapy;

(d) Radiology services;

(e) Nuclear medicine services;

(f) Computerized tomographic (CT) scan;

(g) Operating room services;

(h) Anesthesia services;

(i) Blood storage and processing;

(j) Blood administration;

(k) Other imaging services - Ultrasound;

(l) Pulmonary function services;

(m) Cardiology services;

(n) Recovery room services;

(o) EKG/ECG services;

(p) Gastro-intestinal services;

(q) Inpatient hemodialysis; and

(r) Peripheral vascular laboratory services.

(2) MAA uses the appropriate inpatient or outpatient payment method described in other published WAC to reimburse providers other than LTAC facilities for services and equipment that are covered by MAA but not included in the LTAC fixed per diem rate. The provider must bill MAA directly and MAA reimburses the provider directly.

(3) Transportation services that are related to transporting a client to and from another facility for the provision of outpatient medical services while the client is still an inpatient at the LTAC facility, or related to transporting a client to another facility after discharge from the LTAC facility:

(a) Are not covered or reimbursed through the LTAC fixed per diem rate;

(b) Are not reimbursable directly to the LTAC facility;

(c) Are subject to the provisions in chapter 388-546 WAC; and

(d) Must be billed directly to the:

(i) Department by the transportation company to be reimbursed if the client required ambulance transportation; or

(ii) Department's contracted transportation broker, subject to the prior authorization requirements and provisions described in chapter 388-546 WAC, if the client:

(A) Required nonemergent transportation; or

(B) Did not have a medical condition that required transportation in a prone or supine position.

(4) MAA evaluates requests for covered transportation services that are subject to limitations or other restrictions, and approves such services beyond those limitations or restrictions when medically necessary, under the standards of WAC 388-501-0165.

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Washington State Code Reviser's Office