Medical Assistance.
The Health Care Authority (Authority) administers medical assistance programs, primarily through Medicaid, that pay for health care for low-income state residents who meet certain eligibility criteria. Washington offers a complete medical benefits package to eligible families, children under age 19, low-income adults, certain disabled individuals, and pregnant women. Payments to health care providers and facilities for health care services may be made either directly by the Authority on a fee-for-service basis or through a managed care arrangement.
Medical Assistance Reimbursement for Hospital Stays.
The Authority pays for the hospital stays of medical assistance enrollees if the attending physician orders admission and the admission and treatment meet coverage standards. Hospital services include: emergency room services; hospital room and board, including nursing care; inpatient services, supplies, equipment, and prescription drugs; surgery and anesthesia; diagnostic testing and laboratory work; and radiation and imaging services. The Authority only pays for medically necessary services that are the least costly and equally effective treatment for the client.
Hospitals may receive an "administrative day rate" for days of a hospital stay when a client does not meet the medical necessity criteria for acute inpatient care, but is not discharged because:
The administrative day rate is set annually using the statewide average nursing home rate.
Hospitals may receive payment for any day of a hospital stay in which a patient who is enrolled in a medical assistance program: (1) does not meet the criteria for acute inpatient levels of care; (2) meets the criteria for discharge to any appropriate placement, such as a nursing home, assisted living facility, adult family home, or residential setting funded by the Developmental Disabilities Administration; and (3) is not discharged from the hospital because an appropriate placement is not available.
The Health Care Authority must adopt rules identifying which services are included in the rate and which services may be billed separately. Medically necessary services performed during the stay, pharmacy services, and pharmaceuticals must be billed and paid separately.
The hospital must use any swing beds or skilled nursing beds to the extent that they are available within the hospital for patients who meet skilled nursing care criteria if such a placement meets the patient's care needs, the patient is appropriate for the existing patient mix, and appropriate staffing is available.
The amended bill specifies that the requirement that hospitals use swing beds and skilled nursing beds for patients meeting the payment methodology criteria applies to the extent that those services are available.
The amended bill changes a cross-reference to identify the subsection on the payment methodology, aligns phrasing for consistency, and makes nonsubstantive changes to the ordering of the provisions
(In support) There is an enormous cost to keeping patients who are difficult to discharge in a hospital bed and this bill will offset some of those costs. The administrative day rate for hospitals varies between $280 and $330, while the cost to the hospital for holding the patients is between $800 and $1,600 which is a burden on local hospital districts and may create a lack of beds at a time when many of these hospitals are in financial trouble. A patient who is difficult to discharge in a hospital bed may still need dialysis or cardiac testing or radiological procedures and currently those services are not reimbursed and the cost is absorbed by the hospital. This bill is a needed step forward for reimbursing hospitals for these Medicaid patients. This bill will add more uniformity and consistency in payment and help standardize the process and provide more clarity to plans and hospitals related to paying for and caring for these patients in the hospital. There should be an amendment to clarify that the use of swing beds or skilled nursing beds applies only to the extent those services are available at that hospital.
(Opposed) None.
(Other) Proper reimbursement for services in home and community settings is essential. Many patients are not able to be discharged into home and community-based services because of a lack of nurses and providers. There are currently 50 children on waiting lists to go home because they cannot find a private duty nursing provider. There are additional actions that may be taken to ensure that patients who do not meet inpatient care requirements can be timely discharged from health care facilities. The bill allows a hospital to bill for any service that a patient receives which may create unintentional consequences and disincentivize creating a robust private duty nursing infrastructure because stakeholders might not seek other opportunities for discharge. Single case agreements are common among this population, but Washington does not have a uniform approach to having these approved. Other states have special funds for patients who are difficult to discharge from a hospital and this should be explored to assure that there is a multi-faceted approach to this complex issue.