Effective Date of Rule: August 1, 2007.

     Purpose: The department's new rules and amendments to existing rules ensure clear and consistent policies for hospital reimbursement and ensure compliance with federal and state guidelines. The rules add new sections to: Ensure all disproportionate share hospital (DSH) programs are identified in rule and ensure that sufficient program detail is provided; amend sections pertaining to DSH requirements to ensure consistency with federal guidelines; describe how hospitals qualify for DSH payments; add definitions that apply to DSH payments; amend sections pertaining to the certified public expenditure (CPE) payment program to clarify CPE payment program policies and ensure consistency with federal guidelines embodied in the state plan; and amend sections pertaining to supplemental distributions to approved trauma centers in response to hospital provider input to the department; and incorporate into rule that the department is terminating the upper payment limit (UPL) program.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-550-4925, 388-550-4935, 388-550-4670, 388-550-4900, 388-550-5000, 388-550-5125, 388-550-5130, 388-550-5150, 388-550-5200, 388-550-5210, 388-550-5220, 388-550-5400, 388-550-5410, 388-550-5425, and 388-550-5450.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.500.

      Adopted under notice filed as WSR 07-10-101, 07-10-102, and 07-10-103 on May 1, 2007.

     Changes Other than Editing from Proposed to Adopted Version: WAC 388-550-4900(2) No hospital has a legal entitlement to any DSH payment. &A hospital may receive DSH...

     WAC 388-550-4900 (3)(a) "Base year" means the hospital fiscal year or medicare cost report year that ended during...

     Subsection (3)(g) "Low income utilization rate (LIUR)" means...the sum of these two percentages: (1) the ratio of payments...for patient charity care charges services provided...the ratio of inpatient charity care charges...

     Subsection (3)(h) "Medicaid inpatient utilization rate (MIPUR)" means...its hospital fiscal year or medicare cost report year, divided by...

     Subsection (3)(i) "Medicare cost report year" means the twelve-month period included in the annual cost report a medicare-certified hospital or institutional provider is required by law to submit to its fiscal intermediary.

     Subsection (3)(j) "Nonrural hospital" means...

     Subsection (3)(j)(k)

     Subsection (3)(k)(l) "Service year" means the one...services. The service year may refer to a hospital's fiscal year or medicare cost report year, or to the a state fiscal year.

     Subsection (3)(l)(m)

     Subsection (3)(m)(n) "Uninsured patient" means an individual...When determining the cost...whether the service would have been covered under medicaid and how much the department would have paid for the service had the patient been eligible for medicaid.

     WAC 388-550-4900(4) To be considered for a DSH payment for each SFY, a...by the due date. The due date will be posted on the department's web site. The department will also send notice, by electronic mail, of the DSH application due date to all hospitals that applied for or received DSH payments in the previous SFY.

     WAC 388-550-4900 (10)(e) Plus any adjustments required and/or authorized by federal statute or regulation.

     WAC 388-550-4900(18) If a hospital's submission of incorrect information...recoup the overpayment amount, with interest, in accordance with the provisions of...

     WAC 388-550-4935(3) A hospital that did not...for DSH unless it meets the obstetric services requirement continues to be classified as an acute care hospital serving pediatric and/or adult patients. See WAC 388-550-4900 (5)(b). The hospital must also meet the for the obstetric services and utilization rate requirement requirements for DSH eligibility. See WAC 388-550-4900 (5)(a).

     WAC 388-550-5125(3) The department makes PIIDSH payments to a an eligible hospital on a claim-specific basis.

     WAC 388-550-5130 (section caption) Payment method -- Institution for mental diseases disproportionate share hospital (IMDDSH) and institution for mental diseases (IMD) state grants.

     WAC 388-550-5130(1) A mental psychiatric hospital owned and operated by the state of Washington...

     WAC 388-550-5130(2) For the purposes of the IMDDSH program, the following definitions apply:

     (a) "Institution for mental diseases (IMD)" means a hospital, nursing facility, or other institution of more than sixteen beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

     (b) "Psychiatric community hospital" means a psychiatric hospital other than a state-owned and operated hospital.

     (c) "Psychiatric hospital" means an institution which is primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill persons. The term applies to a medicare-certified distinct psychiatric care unit, a medicare-certified psychiatric hospital, or a state-designated pediatric distinct psychiatric unit in a medicare-certified acute care hospital.

     (d) "State-owned and operated psychiatric hospital" means Eastern State Hospital and Western State Hospital.

     WAC 388-550-5130(3) Except as provided in subsection (4) of this section, a A free-standing psychiatric community hospital facility, regardless of location, is...

     (a) ...

     (b) Any other disproportionate...payment from the department. See WAC 388-550-4800 regarding payment for psychiatric claims for clients eligible under the medical care services programs.

     WAC 388-550-5130(((3)))(4) A free-standing psychiatric facility community hospital within the state of Washington that is designated by the department as an IMD is eligible to receive IMDDSH payments if:

     (a) IMDDSH funds remain available after the amounts appropriated for state-owned and operated psychiatric hospitals are exhausted; and

     (b) The legislature provides funds specifically for this purpose.

     WAC 388-550-5130(5) A psychiatric community hospital within the state of Washington that is designated by the department as an IMD is eligible to receive a state grant amount from the department if the legislature appropriates general funds—state for IMDs funds specifically for this purpose.

     WAC 388-550-5130(6) An institution for mental diseases located out-of-state IMD out of state, including an IMD located in a designated bordering city, is not eligible to receive a Washington state grant amount.

     WAC 388-550-5130 (4)(7) Under...

     WAC 388-550-5200 (1)(d) Be an in-state hospital. A hospital located out-of-state, or in a designated...

     WAC 388-550-5220 (2)(d) Be a hospital that does not...as defined in WAC 388-550-52104900 (3)(m).

     WAC 388-550-5210(3) The department pays...each hospital's individual SRHIAPDSH SRIAPDSH payment...

     WAC 388-550-5210(4) The department's...an exception is required by federal statute or regulation. The...

     WAC 388-550-5220 (2)(c) Be an in-state or bordering city hospital that provided charity services to clients during the base year; and (d) Be a hospital that does no...; and

     Subsection (2)(d) Be an instate or designated bordering city hospital that provided charity services to clients during the base year. For DSH purposes, the department considers as nonrural any hospital located in a designated bordering city.

     WAC 388-550-5400(2) The PHDSH payments to a...according to WAC 388-550-4900(10).

     WAC 388-550-5400(4) A hospital receiving payment...with the services provided during the state fiscal year 2006.

     WAC 388-550-5410 (1)(c) Uninsured patients...must not include the cost of services that medicaid would not have paid for covered had the patients been medicaid eligible; and

     WAC 388-550-5410(3)

     (i) For state fiscal year (SFY) 2006, the deadline for all CPE hospitals to submit the federally required medicaid cost report schedules is June 30, 2007.

     (ii) For SFY 2007 and thereafter, each CPE hospital is

required to submit the medicaid cost report schedules to the department within thirty days after the medicare cost report is due to its medicare fiscal intermediary.

     (iii) For hospitals with a December 31 year end, partial year medicaid cost report schedules for the period July 1, 2005 through December 31, 2005 must be submitted to the department by August 31, 2007.

     (iii) For SFY 2007 and thereafter, each CPE hospital is required to submit the medicaid cost report schedules to the department within thirty days after the medicare cost report is due to its medicare fiscal intermediary.

     A final cost-benefit analysis is available by contacting Ayuni Wimpee, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1835, fax (360) 753-9152, e-mail wimpeah@dshs.wa.gov.

     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 4, Amended 11, 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 4, Amended 11, Repealed 0.

     Date Adopted: June 29, 2007.

Blake D. Chard

for Robin Arnold Williams

Secretary

     (((2) As part of the "hold harmless" payment calculation, the department reprices inpatient hospital claims paid during the service year, beginning with service year SFY 2006, to determine how these claims would have been paid under the payment methodologies in effect during SFY 2005.

     (3) The department makes the final "hold harmless" calculation after the department receives the hospital's final audited Medicare cost report and audited financial statements for the service year. The department calculates the federally required prospective cost settlement at the same time. Any adjustments to state grants payments due to the cost settlement calculations will be made as payment adjustments to the next year's state grants)) (1) For each state fiscal year, the department calculates what the hospital would have been paid under the methodologies otherwise in effect for the state fiscal year (SFY) as the sum of:

     (a) The total payments for inpatient claims for patients admitted during the fiscal year, calculated by repricing the claims using:

     (i) For SFYs 2006 and 2007, the inpatient payment method in effect during SFY 2005;

     (ii) For SFYs 2008 and beyond, the payment method that would otherwise be in effect during the CPE payment program year if the CPE payment program had not been enacted; and

     (b) The total net disproportionate share hospital and state grant payments paid for SFY 2005.

     (2) For each SFY, the department determines total payments made under the program during the fiscal year, including the allowable federal portion of inpatient claims and disproportionate share hospital (DSH) payments, and the state and federal shares of any supplemental upper payment limit payments.

     (3) The amount determined in subsection (2) of this section is subtracted from the amount calculated in subsection (1) of this section to determine the gross state grant amount necessary to hold the hospital harmless. Prepaid hold harmless grants prepaid for the same SFY referred to in subsection (2) of this section are deducted from the gross hold harmless amount to determine the net amount due to or from the hospital.

     (a) The department calculates an interim hold harmless grant amount approximately ten months after the SFY to include the paid claims for the same SFY admissions. Claims are subject to utilization review prior to the interim hold harmless calculation.

     (b) The department calculates the final hold harmless grant amount at such time as the final allowable federal portions of program payments are determined. The procedure is the same as the interim grant calculation but it includes all additional claims that have been paid or adjusted since the interim hold harmless calculation. Claims are subject to utilization review prior to the final calculation of the hold harmless amount due to or from the hospital.

[Statutory Authority: RCW 74.08.090, 74.09.500, and 2005 c 518 § 209(9). 06-11-100, § 388-550-4670, filed 5/17/06, effective 6/17/06.]

     (g) LIDSH)) (42 USC 1396 (a)(13)(A)) and RCW 74.09.730, the department makes payment adjustments to eligible hospitals that serve a disproportionate number of low-income clients with special needs. These adjustments are also known as disproportionate share hospital (DSH) payments.

     (2) No hospital has a legal entitlement to any DSH payment. A hospital may receive DSH payments only if:

     (a) It satisfies the requirements of 42 USC 1396r-4;

     (b) It satisfies all the requirements of department rules and policies; and

     (c) The legislature appropriates sufficient funds.

     (3) For purposes of eligibility for DSH payments, the following definitions apply:

     (a) "Base year" means the hospital fiscal year or medicare cost report year that ended during the calendar year immediately preceding the year in which the state fiscal year for which the DSH application is being made begins.

     (b) "Case mix index (CMI)" means the average of diagnosis related group (DRG) weights for all of an individual hospital's DRG-paid medicaid claims during the state fiscal year (SFY) two years prior to the SFY for which the DSH application is being made.

     (c) "Charity care" means necessary hospital care rendered to persons unable to pay for the hospital services or unable to pay the deductibles or coinsurance amounts required by a third-party payer. The charity care amount is determined in accordance with the hospital's published charity care policy.

     (d) "Disproportionate share hospital (DSH) cap" means the maximum amount per state fiscal year that the state can distribute in DSH payments to hospitals (statewide DSH cap), or the maximum amount of DSH payments a hospital may receive during a state fiscal year (hospital-specific DSH cap).

     (e) "DSH reporting data file (DRDF)" means the information submitted by hospitals to the department which the department uses to verify medicaid patient eligibility and patient days.

     (f) "Hospital-specific DSH cap" means the maximum amount of DSH payments a hospital may receive from the department during a state fiscal year. For a critical access hospital (CAH), the DSH cap is based strictly on the net cost to the hospital of providing services to uninsured patients.

     (g) "Low income utilization rate (LIUR)" means the sum of these two percentages: (1) the ratio of payments received by the hospital for patient services provided to clients under medicaid (including managed care) and state-administered programs, plus cash subsidies received by the hospital from state and local governments for patient services, divided by total payments received by the hospital from all patient categories; plus (2) the ratio of inpatient charity care charges (excluding contractual allowances), divided by total billed charges for inpatient services. The department uses LIUR as one criterion to determine a hospital's eligibility for the low income disproportionate share hospital (LIDSH) program. To qualify for LIDSH, a hospital's LIUR must be greater than twenty-five percent.

     (h) "Medicaid inpatient utilization rate (MIPUR)" means the number of inpatient days of service provided by a hospital to medicaid clients during its hospital fiscal year or medicare cost report year, divided by the number of inpatient days of service provided by that hospital to all patients during the same period.

     (i) "Medicare cost report year" means the twelve-month period included in the annual cost report a medicare-certified hospital or institutional provider is required by law to submit to its fiscal intermediary.

     (j) "Nonrural hospital" means a hospital that is not a peer group E hospital or a small rural hospital and is located inside the state of Washington or in a designated bordering city. For DSH purposes, the department considers as nonrural any hospital located in a designated bordering city.

     (k) "Obstetric services" means routine, nonemergency delivery of babies.

     (l) "Service year" means the one year period used to measure the costs and associated charges for hospital services. The service year may refer to a hospital's fiscal year or medicare cost report year, or to a state fiscal year.

     (m) "Small rural hospital" means a hospital that is not a peer group E hospital, has fewer than seventy-five acute licensed beds, is located inside the state of Washington, and is located in a city or town with a nonstudent population of no more than seventeen thousand one hundred fifteen in calendar year 2006 as determined by the Washington State office of financial management estimate. The nonstudent population ceiling increases cumulatively by two percent each succeeding state fiscal year.

     (n) "Uninsured patient" means an individual who does not have health insurance that would apply to the hospital service the individual sought and received. An individual who did have health insurance that applied to the hospital service the individual sought and received, is considered an insured individual for DSH program purposes, even if the insurer did not pay the full charges for the services. When determining the cost of a hospital service provided to an uninsured patient, the department uses as a guide whether the service would have been covered under medicaid.

     (4) To be considered for a DSH payment for each SFY, a hospital located in the state of Washington or in a designated bordering city must submit to the department a completed and final DSH application by the due date. The due date will be posted on the department's website.

     (5) A hospital is a disproportionate share hospital for a specific SFY if the hospital submits a completed DSH application for that specific year, if it satisfies the utilization rate requirement (discussed in (a) of this subsection), and the obstetric services requirement (discussed in (b) of this subsection).

     (a) The hospital must have a medicaid inpatient utilization rate (MIPUR) greater than one percent; and

     (b) Unless one of the exceptions described in (i)(A) or (B) of this subsection applies, the hospital must have at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to eligible individuals.

     (i) The obstetric services requirement does not apply to a hospital that:

     (A) Provides inpatient services predominantly to individuals younger than age eighteen; or

     (B) Did not offer nonemergency obstetric services to the general public as of December 22, 1987, when section 1923 of the Social Security Act was enacted.

     (ii) For hospitals located in rural areas, "obstetrician" means any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.

     (6) To determine a hospital's eligibility for any DSH program, the department uses the criteria in this section and the information obtained from the DSH application submitted by the hospital, subject to the following:

     (a) Charity care. If the hospital's DSH application and audited financial statements for the relevant fiscal year do not agree on the amount for charity care, the department uses the lower amount listed. For purposes of calculating a hospital's LIUR, the department allows a hospital to claim charity care amounts related to inpatient services only. A hospital must submit a copy of its charity care policy for the relevant fiscal year as part of the hospital's DSH application.

     (b) Total inpatient hospital days. If the hospital's DSH application and its medicare cost report do not agree on the number of total inpatient hospital days, the department uses the higher number listed to determine the hospital's MIPUR. Labor and delivery days count towards total inpatient hospital days. Nursing facility and swing bed days do not count towards total inpatient hospital days.

     (7) The department administers the following DSH programs (depending on legislative budget appropriations):

     (a) Low income disproportionate share hospital (LIDSH);

     (b) Institution for mental diseases disproportionate share hospital (IMDDSH):

     (c) General assistance-unemployable disproportionate share hospital (GAUDSH);

     (d) Small rural disproportionate share hospital (SRDSH);

     (e) Small rural indigent assistance disproportionate share hospital (SRIADSH);

     (f) Nonrural indigent assistance disproportionate share hospital (NRIADSH);

     (g) Public hospital disproportionate share hospital (PHDSH); and

     (h) Psychiatric indigent inpatient disproportionate share hospital (PIIDSH).

     (8) Except for IMDDSH, the department allows a hospital to receive any one or all of the DSH payment adjustments it qualifies for, up to the individual hospital's DSH cap (see subsection (10) of this section). See WAC 388-550-5130 regarding IMDDSH. To be eligible for payment under multiple DSH programs, a hospital must meet:

     (a) The basic requirements in subsection (5) of this section; and

     (b) The eligibility requirements for the particular DSH payment, as discussed in the applicable DSH program WAC.

     (9) For each SFY, the department calculates DSH payments due an eligible hospital using data from the hospital's base year. The department does not use base year data for GAUDSH and PIIDSH payments, which are calculated based on specific claims data.

     (10) The department's total DSH payments to a hospital for any given SFY cannot exceed the individual hospital's annual DSH limit (also known as the hospital-specific DSH cap) for that SFY. Except for critical access hospitals (CAHs), the department determines a hospital's DSH cap as follows:

     (a) The cost to the hospital of providing services to medicaid clients, including clients served under medicaid managed care organization (MCO) plans;

     (b) Less the amount paid by the state under the non-DSH payment provision of the medicaid state plan;

     (c) Plus the cost to the hospital of providing services to uninsured patients;

     (d) Less any cash payments made by or on behalf of uninsured patients; and

     (e) Plus any adjustments required and/or authorized by federal statute or regulation.

     (11) A CAH's DSH cap is based strictly on the cost to the hospital of providing services to uninsured patients. In calculating a CAH's DSH cap, the department deducts payments received by the hospital from and on behalf of the uninsured patients from the hospital's costs of services for the uninsured patients.

     (12) In any given federal fiscal year, the total of the department's DSH payments cannot exceed the statewide DSH cap as published in the federal register.

     (13) If the department's DSH payments for any given federal fiscal year exceed the statewide DSH cap, the department will adjust DSH payments to each hospital to account for the amount overpaid. The department makes adjustments in the following program order:

     (a) PHDSH;

     (b) SRIADSH;

     (c) SRDSH;

     (d) NRIADSH;

     (e) GAUDSH;

     (f) PIIDSH;

     (g) IMDDSH; and

     (h) LIDSH.

     (14) If the statewide DSH cap is exceeded, the department will recoup DSH payments made under the various DSH programs, in the order of precedence described in subsection (13) of this section, starting with PHDSH, until the amount exceeding the statewide DSH cap is reduced to zero. See specific program WACs for description of how amounts to be recouped are determined.

     (15) The total amount the department may distribute annually under a particular DSH program is capped by legislative appropriation, except for PHDSH, GAUDSH, and PIIDSH, which are not fixed pools. Any changes in payment amount to a hospital in a particular DSH pool means a redistribution of payments within that DSH pool. When necessary, the department will recoup from hospitals to make additional payments to other hospitals within that DSH pool.

     (16) If funds in a specific DSH program need to be redistributed because of legislative, administrative, or other state action, only those hospitals eligible for that DSH program will be involved in the redistribution.

     (a) If an individual hospital has been overpaid by a specified amount, the department will recoup that overpayment amount from the hospital and redistribute it among the other eligible hospitals in the DSH pool. The additional DSH payment to be given to each of the other hospitals from the recouped amount is proportional to each hospital's share of the particular DSH pool.

     (b) If an individual hospital has been underpaid by a specified amount, the department will pay that hospital the additional amount owed by recouping from the other hospitals in the DSH pool. The amount to be recouped from each of the other hospitals is proportional to each hospital's share of the particular DSH pool.

     (17) All information submitted by a hospital related to its DSH application is subject to audit. The department may audit any, none, or all DSH applications for a given state fiscal year. The department determines the extent and timing of the audits. For example, the department may choose to do a desk review upon receipt of an individual hospital's DSH application and/or supporting documentation, or audit all hospitals that qualified for a particular DSH program after payments have been distributed under that program.

     (18) If a hospital's submission of incorrect information or failure to submit correct information results in DSH overpayment to that hospital, the department will recoup the overpayment amount, in accordance with the provisions of RCW 74.09.220 and RCW 43.20B.695.

     (19) DSH calculations use fiscal year data, and DSH payments are distributed based on funding for a specific state fiscal year. Therefore, unless otherwise specified, changes and clarifications to DSH program rules apply for the full state fiscal year in which the rules are adopted.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-4900, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, § 388-550-4900, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. 04-12-044, § 388-550-4900, filed 5/28/04, effective 7/1/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, § 388-550-4900, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730 and 42 U.S.C. 1396r-4. 99-14-040, § 388-550-4900, filed 6/30/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-4900, filed 12/18/97, effective 1/18/98.]

[]

     (2) To be considered eligible for DSH, a hospital whose ownership has changed must notify the department in writing no later than thirty days after the change in ownership becomes final. The notice must include the new entity's fiscal year end.

     (3) A hospital that did not offer nonemergency obstetric services to the general public as of December 22, 1987, when section 1923 of the Social Security Act was enacted, and changes ownership after that date is not eligible for DSH unless it continues to be classified as an acute care hospital serving pediatric and/or adult patients. See WAC 388-550-4900(5) for the obstetric services and utilization rate requirements for DSH eligibility.

     (4) If the fiscal year reported on a hospital's medicare cost report does not exactly match the fiscal year reported on the hospital's DSH application to the department, and if therefore the utilization data reported to the department do not agree, the department will use as the data source the document that gives the higher number of total inpatient hospital days for purposes of calculating the hospital's medicaid inpatient utilization rate (MIPUR). See WAC 388-550-4900 (6)(b).

[]

     (2) Hospitals considered eligible under the criteria in subsection (1) of this section receive LIDSH payments. The total LIDSH payment amounts equal the funding set by the state's appropriations act for LIDSH. The amount that the state appropriates for LIDSH may vary from year to year.

     (3) The department ((distributes)) determines LIDSH payments to each LIDSH eligible hospital using ((a prospective payment method. The department determines the standardized Medicaid inpatient utilization rate (MIPUR) by)) three factors:

     (a) ((Dividing)) The hospital's ((MIPUR by the average MIPUR of all LIDSH-eligible hospitals)) medicaid inpatient utilization rate (MIPUR); ((then))

     (b) ((Multiplying)) The hospital's medicaid case mix index (CMI) as determined by the department; and

     (c) The hospital's Title XIX medicaid discharges for the applicable hospital fiscal year.

     (4) The department calculates the LIDSH payment to an eligible hospital as follows. The department:

     (a) Divides the hospital's MIPUR by the average MIPUR of all LIDSH-eligible hospitals; then

     (b) Multiplies the ((hospital's standardized MIPUR)) result derived in subsection (a) by the hospital's most recent DRG payment method ((rebased)) medicaid case mix index, and then by the hospital's ((most recent fiscal)) base year Title XIX ((admissions)) discharges; then

     (c) ((Multiplying the product by an initial random base amount)) Converts the product to a percentage of the sum of all such products for individual hospitals; and ((then))

     (d) ((Comparing the sum of all annual LIDSH payments to the appropriated amount. If the amounts differ, the department progressively selects a new base amount by successive approximation until the sum of the LIDSH payments to hospitals equals)) Multiplies this percentage by the legislatively appropriated amount for LIDSH.

     (((4))) (5) For DSH program purposes, a hospital's medicaid CMI is the average diagnosis related group (DRG) weight for all of the hospital's medicaid DRG-paid claims during the state fiscal year used as the base year for the DSH application. It is possible that the CMI the department uses for DSH calculations will not be the same as the CMI the department uses in other hospital rate calculations.

     (6) After each applicable state fiscal year has ended, the department will not make changes to the LIDSH payment distribution that has resulted from calculations identified in subsection (((3))) (4) of this section. ((However, hospitals may still submit corrected DSH application data to the department after June 15 and prior to July 1 of the applicable state fiscal year to correct calculation of the MIPUR or low income utilization rate (LIUR) for historical record keeping. See WAC 388-550-5550 for rules regarding public notice for changes in Medicaid payment rates for hospital services)) The department will recalculate the LIDSH payment distribution only when the applicable state fiscal year has not yet ended at the time the alleged need for an LIDSH adjustment is identified, and if the department considers the recalculation necessary and appropriate under its regulations.

     (7) Consistent with the provisions of subsection (6) of this section, the department applies any adjustments to the DSH payment distribution required by legislative, administrative, or other state action, to other DSH programs in accordance with the provisions of WAC 388-550-4900 (13) through (16).

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5000, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, § 388-550-5000, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730 and 42 U.S.C. 1396r-4. 99-14-040, § 388-550-5000, filed 6/30/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-5000, filed 12/18/97, effective 1/18/98.]

     (a) Meets the criteria in WAC 388-550-4900 (((2)(b) through (4)(a))) (5);

     (b) Is ((an in-state or bordering city hospital)) not designated an institution for mental diseases (IMD);

     (c) Provides services to clients eligible under the psychiatric indigent inpatient (PII) program. See WAC 388-865-0217 for more information regarding the PII program; and

     (d) ((Qualifies under Section 1923(d) of the Social Security Act)) Is located within the state of Washington. A hospital located out-of-state, including a hospital located in a designated bordering city, is not eligible to receive PIIDSH payments.

     (2) PIIDSH is available only for emergency, voluntary inpatient psychiatric care. PIIDSH is not available for charges for nonhospital services associated with the inpatient psychiatric care.

     (3) The department ((determines the)) makes PIIDSH ((payment for each eligible hospital using a prospective payment method, in accordance with WAC 388-550-4800)) payments to an eligible hospital on a claim-specific basis.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5125, filed 3/30/06, effective 4/30/06.]

     (2) For the purposes of the IMDDSH program, the following definitions apply:

     (a) "Institution for mental diseases (IMD)" means a hospital, nursing facility, or other institution of more than sixteen beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

     (b) "Psychiatric community hospital" means a psychiatric hospital other than a state-owned and operated hospital.

     (c) "Psychiatric hospital" means an institution which is primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill persons. The term applies to a medicare-certified distinct psychiatric care unit, a medicare-certified psychiatric hospital, or a state-designated pediatric distinct psychiatric unit in a medicare-certified acute care hospital.

     (d) "State-owned and operated psychiatric hospital" means Eastern State Hospital and Western State Hospital.

     (3) Except as provided in subsection (4) of this section, a psychiatric community hospital, regardless of location, is not eligible to receive:

     (a) IMDDSH payments; or

     (b) Any other disproportionate share hospital (DSH) payment from the department. See WAC 388-550-4800 regarding payment for psychiatric claims for clients eligible under the medical care services programs.

     (4) A psychiatric community hospital within the state of Washington that is designated by the department as an IMD is eligible to receive IMDDSH payment if:

     (a) IMDDSH funds remain available after the amounts appropriated for state-owned and operated psychiatric hospitals are exhausted; and

     (b) The legislature provides funds specifically for this purpose.

     (5) A psychiatric community hospital within the state of Washington that is designated by the department as an IMD is eligible to receive a state grant amount from the department if the legislature appropriates funds specifically for this purpose.

     (6) An institution for mental diseases located out-of-state, including an IMD located in a designated bordering city, is not eligible to receive a Washington State grant amount.

     (7) Under federal law, 42 USC 1396r-4 (h)(2), the state's annual IMDDSH expenditures are capped at thirty-three percent of the state's annual statewide DSH cap. This amount represents the maximum that the state can spend in any given fiscal year on IMDDSH, but the state is under no obligation to actually spend that amount.

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     (a) Meets the criteria in WAC 388-550-4900 (((2)(b) through (4)(a)));

     (b) Is an in-state or designated bordering city hospital;

     (c) Provides services to clients eligible under the medical care services program; and

     (d) Has a ((low-income utilization rate (LIUR))) medicaid inpatient utilization rate (MIPUR) of one percent or more.

     (2) The department determines the GAUDSH payment for each eligible hospital((, using a prospective payment method,)) in accordance with WAC 388-550-4800((, except that the payment is not reduced by the additional three percent specified in WAC 388-550-4800(4))).

     (3) The department makes GAUDSH payments to a hospital on a claim-specific basis.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5150, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, § 388-550-5150, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. 99-14-025, § 388-550-5150, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-5150, filed 12/18/97, effective 1/18/98.]

     (2))). To qualify for ((a SRHAPDSH)) an SRDSH payment, a hospital must:

     (a) Not be a peer group E hospital;

     (b) Meet the criteria in WAC 388-550-4900 (((2)(b) through (4)(a))) (5);

     (c) Have fewer than seventy-five acute licensed beds; and

     (d) Be an in-state hospital. A hospital located out-of-state or in a designated bordering city is not eligible to receive SRDSH payments;

     (((d) Be a small rural hospital with fewer than seventy-five acute licensed beds; and

     (e))) (2) In addition, for the ((SRHAPDSH)) SRDSH program ((year)) to be implemented for state fiscal year (SFY) ((beginning)) 2008, which begins on July 1, ((2002)) 2007, the city or town must have a nonstudent population of ((fifteen)) no more than seventeen thousand ((five)) one hundred ((or less)) fifteen in calendar year 2006, as determined by the Washington State office of financial management estimate.

     For each subsequent SFY, the nonstudent population ((requirement)) ceiling is increased cumulatively by two percent.

     (3) The department pays hospitals qualifying for ((SRHAPDSH)) SRDSH payments from a legislatively appropriated pool. The department determines each hospital's individual ((SRHAPDSH)) SRDSH payment from the total dollars in the pool using percentages established ((through the following prospective payment method)) as follows:

     (a) At the time the ((SRHAPDSH)) SRDSH payment is to be made, the department calculates each hospital's profitability margin based on ((the most recent, completed year-end)) the hospital's base year data ((using)) and audited financial statements ((from the hospital)).

     (b) The department determines the average profitability margin for the qualifying hospitals.

     (c) Any hospital with a profitability margin of less than one hundred ten percent of the average profitability margin for qualifying hospitals receives a profit factor of 1.1. All other hospitals receive a profit factor of 1.0.

     (d) The department:

     (i) Identifies the medicaid payment amounts made by the department to the individual hospital(('s most recent, completed SFY Medicaid reimbursement amounts)) during the SFY two years prior to the current SFY for which DSH application is being made. These medicaid payment amounts are based on historical data considered to be complete; then

     (ii) Multiplies the total medicaid ((reimbursement)) payment amount determined in subsection (i) by the individual hospital's assigned profit factor (1.1 or 1.0) to identify a revised medicaid ((reimbursement)) payment amount; ((then)) and

     (iii) Divides the revised medicaid ((reimbursement)) payment amount for the individual hospital by the sum of the revised medicaid ((reimbursement)) payment amounts for all qualifying hospitals during the same period.

     (4) The department's ((SRHAPDSH)) SRDSH payments to a hospital may not exceed one hundred percent of the projected cost of care for medicaid clients and uninsured ((indigent)) patients for that hospital unless an exception is ((identified)) required by federal statute or regulation.

     (5) The department reallocates dollars as defined in the state plan.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5200, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. 04-12-044, § 388-550-5200, filed 5/28/04, effective 7/1/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, § 388-550-5200, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. 99-14-025, § 388-550-5200, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-5200, filed 12/18/97, effective 1/18/98.]

     (2) To qualify for an ((SRHIAPDSH)) SRIADSH payment, a hospital must:

     (a) Not be a peer group E hospital;

     (b) Meet the criteria in WAC 388-550-4900 (((2)(b) through (4)(a))) (5);

     (c) Have fewer than seventy-five acute licensed beds; and

     (d) Be an in-state hospital that provided charity services to clients during the ((most recent, completed fiscal)) base year. A hospital located out-of-state or in a designated bordering city is not eligible to receive SRIADSH payments; and

     (((d) Be a small rural hospital with fewer than seventy-five acute licensed beds; and))

     (e) ((For state fiscal year (SFY) beginning July 1, 2003,)) Be located in a city or town ((that has)) with a nonstudent population of ((fifteen)) no more than seventeen thousand ((eight)) one hundred ((ten or less)) fifteen in calendar year 2006, as determined by the Washington State office of financial management estimate. This estimated nonstudent population ceiling is used for SFY 2008, which begins July 1, 2007. For each subsequent SFY, the nonstudent population ((requirement)) ceiling is increased cumulatively by two percent.

     (3) The department pays hospitals qualifying for ((SRHIAPDSH)) SRIADSH payments from a legislatively appropriated pool. The department determines each hospital's individual ((SRHIAPDSH)) SRIADSH payment from the total dollars in the pool using percentages established through the following prospective payment method:

     (a) At the time the ((SRHIAPDSH)) SRIADSH payment is to be made, the department calculates each hospital's profitability margin based on the ((most recent, completed year-end)) hospital's base year data ((using)) and audited financial statements ((from the hospital)).

     (b) The department determines the average profitability margin for ((the qualifying)) all hospitals qualifying for SRIADSH.

     (c) Any qualifying hospital with a profitability margin of less than one hundred ten percent of the average profitability margin for qualifying hospitals receives a profit factor of 1.1. All other qualifying hospitals receive a profit factor of 1.0.

     (d) The department:

     (i) Identifies from historical data considered to be complete, each individual qualifying hospital's allowed charity charges; then

     (ii) Multiplies the total allowed charity charges by the hospital's ratio of costs-to-charges (RCC), limiting the RCC to a value of 1, to determine the hospital's charity costs; then

     (iii) Multiplies the hospital's charity costs by the hospital's profit factor assigned in (c) of this subsection to identify a revised cost amount; then

     (iv) Determines the hospital's percentage of revised costs by dividing its revised cost amount by the sum of the revised charity cost amounts for all qualifying hospitals during the same period.

     (4) The department's ((SRHIAPDSH)) SRIADSH payments to a hospital may not exceed one hundred percent of the projected cost of care for medicaid clients and uninsured indigent patients for that hospital unless an exception is ((identified)) required by federal statute or regulation. The department reallocates dollars as defined in the state plan.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5210, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, § 388-550-5210, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. 04-12-044, § 388-550-5210, filed 5/28/04, effective 7/1/04.]

     (2) To qualify for an ((NRHIAPDSH)) NRIADSH payment, a hospital must:

     (a) Not be a peer group E hospital;

     (b) Meet the criteria in WAC 388-550-4900 (((2)(b) through (4)(a))) (5);

     (c) ((Be an in-state or bordering city hospital that provided charity services to clients during the most recent, completed fiscal year; and

     (d))) Be a hospital that does not qualify as a small rural hospital as defined in WAC ((388-550-5210)) 388-550-4900 (3)(m); and

     (d) Be an in-state or designated bordering city hospital that provided charity services to clients during the base year. For DSH purposes, the department considers as nonrural any hospital located in a designated bordering city.

     (3) The department pays hospitals qualifying for ((NRHIAPDSH)) NRIADSH payments from a legislatively appropriated pool. The department determines each hospital's individual ((NRHIAPDSH)) NRIADSH payment from the total dollars in the pool using percentages established through the following prospective payment method:

     (a) At the time the ((NRHIAPDSH)) NRIADSH payment is to be made, the department calculates each hospital's profitability margin based on the ((most recent, completed year-end)) hospital's base year data ((using)) and audited financial statements ((from the hospital)).

     (b) The department determines the average profitability margin for the qualifying hospitals.

     (c) Any hospital with a profitability margin of less than one hundred ten percent of the average profitability margin for qualifying hospitals receives a profit factor of 1.1. All other hospitals receive a profit factor of 1.0.

     (d) The department:

     (i) Identifies from historical data considered to be complete, each individual qualifying hospital's allowed charity charges; then

     (ii) Multiplies the total allowed charity charges by the hospital's ratio of costs-to-charges (RCC), limiting the RCC to a value of 1, to determine the hospital's charity costs; then

     (iii) Multiplies the hospital's charity costs by the hospital's profit factor assigned in (c) of this subsection to identify a revised cost amount; then

     (iv) Determines the hospital's percentage of the ((NRHIAPDSH)) NRIADSH revised costs by dividing the hospital's revised cost amount by the total revised charity costs for all qualifying hospitals during the same period.

     (4) The department's ((NRHIAPDSH)) NRIADSH payments to a hospital may not exceed one hundred percent of the projected cost of care for medicaid clients and uninsured indigent patients for the hospital unless an exception is ((identified)) required by federal statute or regulation. The department reallocates dollars as defined in the state plan.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5220, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, § 388-550-5220, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. 04-12-044, § 388-550-5220, filed 5/28/04, effective 7/1/04.]

     (a) Public hospitals located in the state of Washington that are:

     (i) Owned by a public hospital district((s)); and

     (ii) Not certified by the department of health (DOH) as a critical access hospital;

     (b) Harborview Medical Center; and

     (c) University of Washington Medical Center.

     (2) The ((department pays)) PHDSH payments to a hospital((s)) eligible under this program ((a payment equal to)) may not exceed the hospital's ((individual)) disproportionate share hospital (DSH) ((payment limit)) cap calculated according to WAC 388-550-4900(10). The ((resulting amount is multiplied by)) hospital receives only the federal matching assistance percentage ((in effect for Washington State at the time of the payment. This amount is sent to the hospital)) of the total computable payment amount.

     (3) Hospitals receiving payment under ((this DSH)) the PHDSH program must ((certify that funds have been spent on uncompensated care at the hospital equal to or in excess of the payment amount before applying the federal matching assistance percentage)) provide the local match for the federal funds through certified public expenditures (CPE). Payments are limited to costs incurred by the participating hospitals.

     (4) A hospital receiving payment under the PHDSH program must submit to the department federally required medicaid cost report schedules apportioning inpatient and outpatient costs, beginning with the services provided during state fiscal year 2006. See WAC 388-550-5410.

     (5) PHDSH payments are subject to the availability of DSH funds under the statewide DSH cap. If the statewide DSH cap is exceeded, the department will recoup PHDSH payments first, but only from hospitals that received total inpatient and DSH payments above the hold harmless level, and only to the extent of the excess amount above the hold harmless level. See WAC 388-550-4900 (13) and (14), and WAC 388-550-4670.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5400, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, § 388-550-5400, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, § 388-550-5400, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. 99-14-025, § 388-550-5400, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-5400, filed 12/18/97, effective 1/18/98.]

     (a) Title XIX fee-for-service claims;

     (b) Medicaid managed care organization (MCO) plan claims;

     (c) Uninsured patients (individuals who are not covered under any health care insurance plan for the hospital service provided). The cost report schedules for uninsured patients must not include services that medicaid would not have covered had the patients been medicaid eligible; and

     (d) State-administered program patients. State-administered program patients are reported separately and are not to be included on the Uninsured patient cost report schedule. The department will provide Provider Statistics and Reimbursements (PS&R) reports for the state-administered program claims.

     (2) The department requires each CPE hospital to submit medicaid cost report schedules to the department for services provided to patients discharged on or after July 1, 2005.

     (3) A CPE hospital must:

     (a) Use the information on individualized PS&R reports provided by the department when completing the medicaid cost report schedules. The department provides the hospital with the PS&R reports at least thirty days prior to the appropriate deadline.

     (i) For state fiscal year (SFY) 2006, the deadline for all CPE hospitals to submit the federally required medicaid cost report schedules is June 30, 2007.

     (ii) For hospitals with a December 31 year end, partial year medicaid cost report schedules for the period July 1, 2005 through December 31, 2005 must be submitted to the department by August 31, 2007.

     (iii) For SFY 2007 and thereafter, each CPE hospital is required to submit the medicaid cost report schedules to the department within thirty days after the medicare cost report is due to its medicare fiscal intermediary.

     (b) Complete the cost report schedules for medicaid MCO plan and the uninsured patients using the hospital provider's records.

     (c) Comply with the department's instructions regarding how to complete the required cost report schedules.

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     (c) Must be used by the receiving hospital(s) to improve health care services to low income patients)) The upper payment limit (UPL) program is terminated effective July 1, 2007. The department will not make UPL payments after June 30, 2007.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5425, filed 3/30/06, effective 4/30/06.]

     (2) Beginning with trauma services provided after June 30, 2003, the department makes supplemental distributions from the TCF to qualified hospitals, subject to the provisions in this section and subject to legislative action.

     (3) To qualify for supplemental distributions from the TCF, a hospital must:

     (a) Be designated or recognized by the department of health (DOH) as an approved Level 1, Level 2, or Level 3 adult or pediatric trauma service center;

     (b) Meet the provider requirements in this section and other applicable WAC;

     (c) Meet the billing requirements in this section and other applicable WAC;

     (d) Submit all information the department requires to ensure services are being provided; and

     (e) Comply with DOH's Trauma Registry reporting requirements.

     (4) Supplemental distributions from the TCF are:

     (a) ((For qualified hospitals, determined as a percentage of a fixed amount per quarter. Each eligible hospital's share per quarter is based on the amount paid by the department to that hospital for inpatient and outpatient trauma care the hospital provides to Medicaid clients during that quarter, expressed as a percentage of the following total)) Allocated into five fixed payment pools of equal amounts. Timing of payments is described in subsection (5) of this section. Distributions from the payment pools to the individual hospitals are determined by first summing each eligible hospital's qualifying payments since the beginning of the service year and expressing this amount as a percentage of total payments to all eligible hospitals for qualifying services provided during the service year to date. Each hospital's payment percentage is multiplied by the available amount in the current period pool to determine the portion of the pool to be paid to each qualifying hospital. Eligible hospitals and qualifying payments are described in (i) through (iii) of this subsection:

     (i) Qualifying payments are the department's payments to Level 1, Level 2, and Level 3 trauma service centers for qualified medicaid trauma cases ((in that quarter)) since the beginning of the service year. The department determines the countable payment ((per quarter)) for trauma care provided to medicaid clients based on date of service, not date of payment;

     (ii) The department's payments to Level 1, Level 2, and Level 3 hospitals for trauma cases transferred in ((during that quarter)) since the beginning of the service year. A Level 1, Level 2, or Level 3 hospital that receives a transferred trauma case from any lower level hospital is eligible for the enhanced payment, regardless of the client's Injury Severity Score (ISS). An ISS is a summary rating system for traumatic anatomic injuries; and

     (iii) The department's payments to Level 2 and Level 3 hospitals for qualified trauma cases (those that meet or exceed the ISS criteria in subsection (4)(b) of this section) that ((are)) these hospitals transferred to a higher level designated trauma service center ((during that quarter)) since the beginning of the service year.

     (b) Paid only for a medicaid trauma case that meets:

     (i) The ISS of thirteen or greater for an adult trauma patient (a client age fifteen or older);

     (ii) The ISS of nine or greater for a pediatric trauma patient (a client younger than age fifteen); or

     (iii) The conditions of subsection (4)(c).

     (c) Made to hospitals, as follows, for a trauma case that is transferred:

     (i) A hospital that receives the transferred trauma case qualifies for payment regardless of the ISS if the hospital is designated or recognized by DOH as an approved Level 1, Level 2, or Level 3 adult or pediatric trauma service center;

     (ii) A hospital that transfers the trauma case qualifies for payment only if:

     (A) It is designated or recognized by DOH as an approved Level 2 or Level 3 adult or pediatric trauma service center; and

     (B) The ISS requirements in (b)(i) or (b)(ii) of this subsection are met.

     (iii) A hospital that DOH designates or recognizes as an approved Level 4 or Level 5 trauma service center does not qualify for supplemental distributions for ((transferred)) trauma cases that are transferred in or transferred out, even when the transferred cases meet the ISS criteria in subsection (4)(b) of this section.

     (d) Not funded by disproportionate share hospital (DSH) funds; and

     (e) Not distributed by the department to:

     (i) Trauma service centers designated or recognized as Level 4 or Level 5;

     (ii) Critical access hospitals (CAHs), except when the CAH is also a Level 3 trauma service center. Beginning with qualifying trauma services provided in state fiscal year (SFY) 2007, the department allows a hospital with this dual status to receive distributions from the TCF; or

     (iii) Any hospital for follow-up surgical services related to the qualifying trauma incident but provided to the client after the client has been discharged for the initial qualifying injury.

     (5) Distributions for an SFY are divided into five "quarters" and paid as follows:

     (a) Each quarterly distribution paid by the department from the TCF totals twenty percent of the amount designated by the department for that SFY;

     (b) The first quarterly supplemental distribution from the TCF is made six months after the SFY begins;

     (c) Subsequent quarterly payments are made approximately every four months after the first quarterly payment is made, except as described in subsection (d);

     (d) The "fifth quarter" final distribution from the TCF for the same SFY is:

     (i) Made one year after the end of the SFY;

     (ii) Based on the SFY that the TCF designated amount relates to; and

     (iii) Distributed based on each eligible hospital's percentage of the total payments made by the department to all designated trauma service centers for qualified trauma cases during the relevant fiscal year.

     (6) For purposes of the supplemental distributions from the TCF, all of the following apply:

     (a) The department may consider a request for a claim adjustment submitted by a provider only if the request is received by the department within one year from the date of the initial trauma service;

     (b) The department does not allow any carryover of liabilities for a supplemental distribution from the TCF ((after a date specified by the department as the last date to make)) beyond three hundred sixty-five calendar days from the date of discharge (inpatient) or date of service (outpatient). The deadline for making adjustments to a trauma claim ((for an SFY)) is the same as the deadline for submitting the initial claim to the department. WAC 388-502-0150(7) does not apply to TCF claims;

     (c) All claims and claim adjustments are subject to federal and state audit and review requirements; and

     (d) The total amount of supplemental distributions from the TCF disbursed to eligible hospitals by the department in any biennium cannot exceed the amount appropriated by the legislature for that biennium. The department has the authority to take whatever actions necessary to ensure the department stays within the TCF appropriation.

[Statutory Authority: RCW 74.08.090, 74.09.500. 06-08-046, § 388-550-5450, filed 3/30/06, effective 4/30/06; 04-19-113, § 388-550-5450, filed 9/21/04, effective 10/22/04.]

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