WSR 17-18-011 EMERGENCY RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed August 24, 2017, 2:47 p.m., effective August 24, 2017, 2:47 p.m.] Effective Date of Rule: Immediately upon filing. Purpose: The agency is revising the requirements a hospital must meet to perform and be paid for bariatric surgery provided to eligible apple health clients. To qualify, a hospital must be accredited by the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP). Citation of Rules Affected by this Order: Amending WAC 182-550-2301. 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. Reasons for this Finding: Under the current rules, one hospital in Washington state is approved to perform and be paid for bariatric surgery for apple health clients. The approved hospital does not serve the entire state. This creates an access to care issue for apple health clients located in counties which the approved hospital does not serve. This emergency rule is necessary to lessen the existing requirements to accreditation by MBSAQIP while the permanent rules are promulgated. The agency filed the CR-101 for the permanent rules process under WSR 17-18-010, on August 24, 2017. Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0. Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0. Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0. Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0. Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: August 24, 2017. Wendy Barcus Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-18-065, filed 8/27/15, effective 9/27/15)
WAC 182-550-2301 Hospital and medical criteria requirements for bariatric surgery.
(1) The medicaid agency pays a hospital for bariatric surgery and bariatric surgery-related services only when the surgery is provided in an inpatient hospital setting and only when:
(a) The client:
(i) Qualifies for bariatric surgery by successfully completing all requirements under WAC 182-531-1600; and
(((b) The client)) (ii) Continues to meet the criteria to qualify for bariatric surgery under WAC 182-531-1600 up to the actual surgery date((;
(c) The hospital providing the bariatric surgery and bariatric surgery-related services meets the requirements in this section and other applicable WAC; and
(d))).
(b) The hospital:
(i) Is accredited by the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP); and
(ii) Receives prior authorization from the agency before performing a bariatric surgery for a Washington apple health client.
(2) ((A hospital must meet the following requirements to be paid for bariatric surgery and bariatric surgery-related services provided to an eligible Washington apple health client. The hospital must:
(a) Be approved by the agency to provide bariatric surgery and bariatric surgery-related services and:
(i) For dates of admission after June 30, 2007, be located in Washington state or approved bordering cities (see WAC 182-501-0175).
(ii) For dates of admission after June 30, 2007, be located in Washington state, or be an agency-designated critical border hospital.
(b) Have an established bariatric surgery program in operation under which at least one hundred bariatric surgery procedures have been performed. The program must have been in operation for at least five years and be under the direction of an experienced board-certified surgeon. In addition, the agency requires the bariatric surgery program to:
(i) Have a mortality rate of two percent or less;
(ii) Have a morbidity rate of fifteen percent or less;
(iii) Document patient follow-up for at least five years postsurgery;
(iv) Have an average loss of at least fifty percent of excess body weight achieved by patients at five years postsurgery; and
(v) Have a reoperation or revision rate of five percent or less.
(c) Submit documents to the agency's division of health care services that verify the performance requirements listed in this section.
(3) The agency waives the program requirements listed in subsection (2)(b) of this section if the hospital participates in a statewide bariatric surgery quality assurance program such as the surgical Clinical Outcomes Assessment Program (COAP).
(4))) See WAC 182-531-1600(13) for requirements for surgeons who perform bariatric surgery.
(((5))) (3) Authorization does not guarantee payment. Authorization for bariatric surgery and bariatric surgery-related services is valid only if:
(a) The client is eligible on the date of admission and date of service; and
(b) The hospital and professional providers meet the criteria in this section and other applicable WAC to perform bariatric surgery or to provide bariatric surgery-related services.
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