S-4979.2

SENATE BILL 6358

BySenators Randall, Short, and Wilson, C.

AN ACT Relating to requiring medicaid managed care organizations to provide reimbursement of health care services provided by substitute providers; and adding a new section to chapter 74.09 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1. A new section is added to chapter 74.09 RCW to read as follows:

(1) In order to protect patients and ensure that they benefit from seamless quality care when contracted providers are absent from their practices or when there is a temporary vacancy in a position while a hospital, rural health clinic, or rural provider is recruiting to meet patient demand, hospitals, rural health clinics, and rural providers may use substitute providers to provide services. Medicaid managed care organizations must allow for the use of substitute providers and provide payment consistent with the provisions in this section.

(2) Hospitals, rural health clinics, and rural providers may use substitute providers when:

(a) A contracted provider is absent for a limited period of time due to vacation, illness, disability, continuing medical education, or other short-term absence; or

(b) A hospital, rural health clinic, or rural provider is recruiting to fill an open position.

(3) For a substitute provider providing services under subsection (2)(a) of this section, the substitute provider may bill and receive payment for services under the contracted provider's national provider identifier for up to sixty days.

(4) Enrollment of a substitute provider in a medicaid managed care organization is effective on the later of:

(a) The date the substitute provider filed an enrollment application that was subsequently approved; or

(b) The date the substitute provider first began providing services at the hospital, rural health clinic, or rural provider.

(5) Substitute providers may retrospectively bill for services for up to thirty days prior to their effective date under subsection (4) of this section if:

(a) The substitute provider has met all program requirements, including state licensure requirements; and

(b) Circumstances precluded enrollment in advance of providing services to medicaid beneficiaries.

(6) Nothing in this section obligates a managed care organization to enroll any substitute provider who requests enrollment if they do not meet the organizations enrollment criteria.

(7) For purposes of this section:

(a) "Circumstances precluded enrollment" means that the provider has met all program requirements including state licensure during the thirty-day period before an application was submitted and no final adverse determination precluded enrollment. If a final adverse determination precluded enrollment during this thirty-day period, the contractor shall only establish an effective billing date the day after the date that the final adverse action was resolved, as long as it is not more than thirty days prior to the date on which the application was submitted.

(b) "Contracted provider" means a provider who is contracted with a medicaid managed care organization.

(c) "Hospital" means a facility licensed under chapter 70.41 or 71.12 RCW.

(d) "Rural health clinic" means a federally designated rural health clinic.

(e) "Rural provider" means physicians licensed under chapter 18.71 RCW, osteopathic physicians and surgeons licensed under chapter 18.57 RCW, physician assistants licensed under chapter 18.71A RCW, osteopathic physician assistants licensed under chapter 18.57A RCW, and advanced registered nurse practitioners licensed under chapter 18.79 RCW, who are located in a rural county as defined in RCW 82.14.370.

(f) "Substitute provider" includes physicians licensed under chapter 18.71 RCW, osteopathic physicians and surgeons licensed under chapter 18.57 RCW, physician assistants licensed under chapter 18.71A RCW, osteopathic physician assistants licensed under chapter 18.57A RCW, and advanced registered nurse practitioners licensed under chapter 18.79 RCW.

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