EMERGENCY RULES
SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)
Effective Date of Rule: Immediately.
Purpose: Upon order of the governor, the medicaid purchasing administration must reduce its budget expenditures for the current fiscal year ending June 30, 2011, by 6.3 percent. This cost-saving measure is required to amend the rule to bring department payment methodology for qualified medicare beneficiary (QMB) clients into alignment with the payment formula established in WAC 388-502-0110 for medicare/medicaid dual-eligible QMB clients.
Citation of Existing Rules Affected by this Order: Amending WAC 388-517-0320.
Statutory Authority for Adoption: RCW 74.08.090.
Other Authority: 42 U.S.C. § 1396a (n)(2).
Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal years 2009, 2010, or 2011, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.
Reasons for this Finding: Governor Gregoire issued Executive Order 10-04 on September 13, 2010, under the authority of RCW 43.88.110(7). In the executive order, the governor required DSHS and all other state agencies to reduce their expenditures in state fiscal year 2011 by approximately 6.3 percent.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.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 0, Amended 1, Repealed 0.
Date Adopted: May 3, 2011.
Katherine I. Vasquez
Rules Coordinator
4295.1(a) Medicare Part A premiums (if any);
(b) Medicare Part B premiums;
(c) Coinsurance, deductibles, and copayments for medicare Part A, Part B, and medicare advantage Part C with the following conditions:
(i) Only the Part A and Part B deductible, coinsurance, and copayments up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110), if the service is covered by medicare and medicaid.
(ii) Only the deductible, coinsurance, and copayments up to the medicare allowed amount if the service is covered only by medicare.
(d) Copayments for QMB-eligible clients enrolled in medicare advantage Part C up to the medicare or medicaid allowed amount whichever is less (WAC 388-502-0110).
(e) QMB Part A and/or Part B premiums the first of the month following the month the QMB eligibility is determined)) medicare Part A premiums (if any) and medicare Part B premiums the first of the month following the month the QMB eligibility is determined. The department pays medicare coinsurance, deductibles, and copayments for medicare Part A, Part B and medicare advantage Part C.
(2) For specified low-income medicare beneficiary (SLMB) clients, the department pays medicare Part B premiums effective up to three months prior to the certification period if eligible for those months. No other payments are made for SLMBs.
(3) For qualified individual (QI-1) clients, the department pays medicare Part B premiums effective up to three months prior to the certification period if eligible for those months unless:
(a) The client receives medicaid categorically needy (CN) or medically needy (MN) benefits; and/or
(b) The department's annual federal funding allotment is spent. The department resumes QI-1 benefit payments the beginning of the next calendar year.
(4) For qualified disabled working individual (QDWI) clients, the department pays medicare Part A premiums effective up to three months prior to the certification period if eligible for those months. The department stops paying medicare Part A premiums if the client begins to receive CN or MN medicaid.
(5) For state-funded medicare buy-in program clients, the
department pays((:
(a) Medicare Part B premiums; and
(b) Only the Part A and B co-insurance, deductibles, and copayments up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110), if the service is covered by medicare and medicaid.
(6) For the dual-eligible client, (a client receiving both medicare and CN or MN medical coverage) the department pays as follows:
(a) If the service is covered by medicare and medicaid, medicaid pays only the deductible, and coinsurance up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110); and
(b) Copayments for medicare advantage Part C up to the medicare or medicaid allowed copayment amount, whichever is less (WAC 388-502-0110);
(c) If no medicaid rate exists, the department will deny payment unless the client is also QMB then refer to section (1) above)) medicare Part B premiums. Cost sharing for medicare deductibles, copayments and co-insurance is paid by the categorically needy (CN) or medically needy (MN) medicaid program.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530 and 42 U.S.C. Section 1396a. 07-15-032, § 388-517-0320, filed 7/12/07, effective 8/12/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). 05-14-125, § 388-517-0320, filed 7/1/05, effective 8/1/05.]