PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Health and Rehabilitative Services Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 00-08-048.
Title of Rule: Chapter 275-16 WAC, Liability for costs of care and hospitalization of the mentally ill.
Purpose: Compliance with the executive order on regulatory improvement and to update references to law and other regulations, add one definition and modify two others, delete part of one section and increase the monthly exempt income of a patient. The rewritten rules will be renumbered into chapter 388-855 WAC.
Statutory Authority for Adoption: RCW 43.20B.335, 43.20B.325, 72.01.090, 71.05.560.
Statute Being Implemented: RCW 71.20.090.
Summary: Patients who are financially able to do so must pay for care at the state psychiatric hospitals. This rule describes how costs and ability to pay are determined. It also sets the consequences of failing to cooperate with the department, and gives the right to petition for review of the department's decision.
Reasons Supporting Proposal: Efficient use of state resources.
Name of Agency Personnel Responsible for Drafting: Paul Bigelow, OB-2, Olympia, (360) 902-0817; Implementation and Enforcement: Camille Pedersen, Office of Financial Recovery, (360) 664-5470.
Name of Proponent: Department of Social and Health Services, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: This proposal allows the state to collect payment for care in the state psychiatric hospitals from patients who are able to pay for their care. The proposal describes how state hospital costs are determined, and how ability to pay is determined. The proposal also describes the consequences for failure to cooperate with the department, and to appeal departmental decisions.
Proposal Changes the Following Existing Rules: The proposal defines "responsible relative" and further defines gross income.
No small business economic impact statement has been prepared under chapter 19.85 RCW. Health and Rehabilitative Services Administration has analyzed the proposed chapter and concludes the proposed changes do not impact small businesses. Therefore, a small business economic impact statement is not required.
RCW 34.05.328 applies to this rule adoption. The proposed changes make significant amendments to a policy or regulatory program. However, the department is exempt from the analysis required under RCW 34.05.328 for rules that relate only to client medical or financial eligibility and rules concerning liability for care of dependents. Therefore no analysis was prepared. Other changes made were technical corrections only.
Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on October 10, 2000, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Kelly Cooper, DSHS Rules Coordinator, by October 3, 2000, phone (360) 664-6094, TTY (360) 664-6178, e-mail myercme@dshs.wa.gov [coopekd@dshs.wa.gov].
Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by October 10, 2000.
Date of Intended Adoption: No sooner than October 11, 2000.
August 15, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2806.2
(((1))) "Adjusted charges" are
those charges levied upon a patient who is or has been confined
to a state hospital for the mentally ill, either by voluntary or
involuntary admission, and their estates and responsible
relatives, which are less than the actual cost of hospitalization
as reflected in the schedule of charges herein and which has been
established by the issuance of a notice of finding of
responsibility.
(((2))) "Adjusted gross income" is that gross income of the
estate of the patient and responsible relatives less any
deductions, contributions or payments mandated by law including,
but not necessarily limited to, income tax and social security.
(((3))) "Dependent" means any spouse, minor son or daughter,
or permanently disabled son or daughter, of the patient living in
the patient's household. If the patient is a minor, then the
same definitions shall apply in determining the dependency of
members of the parent's household. If a minor son or daughter is
not living in the patient's household, that son or daughter shall
not be considered a dependent unless the patient is in fact
contributing more than fifty percent of that child's support in
accordance with a court order or court-recognized agreement.
(((4))) "Department" means the department of social and
health services.
(((5))) "Determination officer" is that duly appointed and
qualified claims investigator who is delegated authority by the
secretary to conduct or cause to have conducted an investigation
of the financial condition of the estate of the patient and
responsible relatives; to evaluate the results of such
investigations; to make determinations of the ability to pay
hospitalization changes from such investigations and
evaluations; and to issue notices of findings of responsibility
to the responsible parties.
(((6))) "Estate of patient and responsible relative" means
the total assets available to the patient and his responsible
relatives to reimburse the department for hospitalization charges
incurred by the patient in a state hospital for the mentally ill
in accordance with these regulations.
(((7))) "Gross income" means the total assets available to
the estate of the patient and responsible relatives expressed in
terms of their cash equivalent on a monthly basis. ((It)) The
total assets available to the estate of the patient and
responsible relatives are converted to a monthly cash equivalent
figure by dividing those assets by twelve months. Gross income
includes all of the following calculated prior to any mandatory
deductions; gross wages for service; net earnings from
self-employment; and all other assets ((of the estate prior to
any mandatory deductions)) divided by twelve months.
(((8))) "Responsible relative" includes the spouse of a
patient, or the parent of a patient who is under eighteen years
of age.
"Secretary" means the secretary of the department of social and health services.
[Statutory Authority: RCW 81.02.412 [71.02.412]. 81-08-020 (Order 1627), § 275-16-015, filed 3/25/81.]
(1) The department will include, but not necessarily be limited to, in their determination of the assets of the estates of present and former patients of state hospitals for the mentally ill and their responsible relatives, cash, stocks, bonds, savings, security interests, insurance benefits, guardianship funds, trust funds, governmental benefits, pension benefits and personal property.
(2) Real property shall also be an available asset to the
estate: Provided, That the patient's home shall not be
considered an available asset if that property is owned by the
estate and serves as the principal dwelling and actual residence
of the patient, the patient's spouse, and/or minor children and
disabled sons or daughters: Provided further, That if the home
is not being used for residential purposes by the patient, the
patient's spouse, and/or minor children and disabled sons or
daughters, and in the opinion of two physicians, there is no
reasonable expectancy that the patient will be able to return to
the home during the remainder of his life, the home shall be
considered an asset available to the estate((.
(3) In determining if a particular asset is available to the estate of a patient who is eligible or potentially eligible for Medicaid, the determination officer will apply the standards of WAC 388-92-045)).
[Statutory Authority: RCW 81.02.412 [71.02.412]. 81-08-020 (Order 1627), § 275-16-035, filed 3/25/81.]
Patients whose total
resources are insufficient to pay for the actual cost of care
shall be entitled to a monthly exemption from income in the
amount of (($25)) forty-one dollars and sixty-two cents or such
amount as specified in WAC ((388-29-125)) 388-478-0040.
[Statutory Authority: RCW 72.01.090. 78-03-029 (Order 1270), § 388-16-045 (codified as WAC 275-16-045), filed 2/17/78.]
(1) The determination officer's assessment of the ability and liability of a person or of the person's estate to pay hospitalization charges shall be issued in the form of a notice and finding of responsibility (NFR) as prescribed by RCW 43.20B.340.
(2) When the NFR is for full hospitalization charges as
specified under WAC ((275-16-030)) 388-855-0030, the department
shall:
(a) Inform the financially responsible person of the current charges; and
(b) Periodically recompute the financially responsible person's charges.
(3) When the NFR is for adjusted charges, the department shall:
(a) Express the charges in a daily or monthly rate; and
(b) Set aside charges for ancillary services.
(4) The right to an adjudicative proceeding to contest the NFR is contained in RCW 43.20B.340.
(a) A financially responsible person wishing to contest the NFR shall, within twenty-eight days of receipt of the NFR:
(i) File a written application for an adjudicative proceeding showing proof of receipt with the Secretary, DSHS, Attn: Determination Officer, P.O. Box 9768, Olympia, WA 98504; and
(ii) Include in or with the application:
(A) A specific statement of the issues and law involved;
(B) The grounds for contesting the department decision; and
(C) A copy of the contested NFR.
(b) The proceeding shall be governed by the Administrative
Procedure Act (chapter 34.05 RCW), RCW 43.20B.340, this chapter,
and chapter ((388-08)) 388-02 WAC. If any provision in this
chapter conflicts with chapter ((388-08)) 388-02 WAC, the
provision in this chapter governs.
[Statutory Authority: RCW 71.05.560. 90-21-030 (Order 3083), § 275-16-055, filed 10/9/90, effective 11/9/90. Statutory Authority: RCW 34.05.220 (1)(a) and 43.20B.335. 90-04-075 (Order 3001), § 275-16-055, filed 2/5/90, effective 3/1/90. Statutory Authority: RCW 81.02.412 [71.02.412]. 81-08-020 (Order 1627), § 275-16-055, filed 3/25/81.]
(1) In determining the ability of the estate of the patient and responsible relative to pay hospitalization charges, first priority shall be given to any third party benefits which might be available. The availability of third party benefits, such as medical insurance, health insurance, Medicare, Medicaid, CHAMPUS, CHAMPVA, shall be considered as an available asset of the estate and shall justify a finding for actual costs of hospitalization during such period as the coverage is in effect.
(2) In the absence of third party benefits, charges shall be based upon the available assets of the estate giving consideration to any unusual and exceptional circumstances and other pertinent factors. No financial determination of the ability of the estate to pay hospitalization charges shall conflict with the eligibility requirements for Medicaid for those patients who are eligible or potentially eligible for such benefits.
(3) The ability of the estate to pay adjusted charges will be determined by applying the following formula:
| X | = | (Z-E)F |
| Where Z | = | (A-Y-N-R)÷D |
| Z | = | available income per family member |
| X | = | adjusted charges (daily) |
| A | = | gross income |
| Y | = | mandatory deductions |
| N | = | allowance for unusual and exceptional circumstances |
| R | = | allowance for other pertinent factors |
| D | = | number of dependents |
| E | = | exempt income |
| F | = | a factor which converts the monthly figures to a daily rate (.0328767). |
(4) The adjusted gross income (A-Y) is determined by first
developing the gross income of the estate of the patient and the
responsible relative. Gross income (A) includes not only gross
wages for services rendered, and/or net earnings from
self-employment, but all other available assets ((converted to
some reasonable)) which have been divided by twelve months to
convert them to a monthly cash equivalent figure. All mandatory
deductions (Y), such as income tax and social security, are
deducted from the gross income to arrive at the adjusted gross
income.
(5) Approved allowances for unusual and exceptional circumstances (N) and for other pertinent factors (R) are then subtracted from the adjusted gross income.
(6) The available income (A-Y-N-R) is then divided by the number of dependents in the household of the patient (D) to determine the available income per family member.
(7) Exempt income (E) as defined in WAC ((275-16-045))
388-855-0045 is then subtracted from the available income per
family member to arrive at the monthly adjusted charges.
(8) The monthly adjusted charges are multiplied by the factor of .0328767 which converts the monthly figure to a daily rate.
[Statutory Authority: RCW 81.02.412 [71.02.412]. 81-08-020 (Order 1627), § 275-16-065, filed 3/25/81.]
The determination officer may consider the following other pertinent factors in determining the ability of the estate of the patient and responsible relatives to pay.
(1) The determination officer may consider those factors related to the well-being, education and training, child support obligations set by court order or by administrative finding under chapter 74.20A RCW, and/or rehabilitation of the patient and the patient's immediate family, to whom the patient owes a duty of support. The patient and/or responsible relatives shall show the existence and the necessity for the pertinent factors as defined. Upon such a showing, the determination officer may consider such resources necessary to reasonably provide for such pertinent factors as assets not available to the estate of the patient and responsible relatives.
(2) Consistent with RCW 43.20B.335, the determination
officer shall consider a judgment owed by the patient to any
victim of an act that would have resulted in criminal conviction
of the patient but for a finding of the patient's criminal
insanity. A victim shall include an estate's personal
representative who has obtained judgment for wrongful death
against the criminally insane patient((.
(3) The department shall ensure that any allowance for other pertinent factors does not conflict with Medicaid eligibility requirements for those patients who are eligible or potentially eligible for such benefits)).
[Statutory Authority: RCW 43.20B.335. 96-18-090, § 275-16-085, filed 9/4/96, effective 10/5/96. 81.02.412 [71.02.412]. Statutory Authority: RCW 81-08-020 (Order 1627), § 275-16-085, filed 3/25/81.]
The following sections of the Washington Administrative
Code, as amended, are recodified as follows:
| Old WAC Number | New WAC Number |
| 275-16-015 | 388-855-0015 |
| 275-16-035 | 388-855-0035 |
| 275-16-045 | 388-855-0045 |
| 275-16-055 | 388-855-0055 |
| 275-16-065 | 388-855-0065 |
| 275-16-085 | 388-855-0085 |
NEW SECTION
The following sections of the Washington Administrative Code
are recodified as follows:
| Old WAC Number | New WAC Number |
| 275-16-010 | 388-855-0010 |
| 275-16-030 | 388-855-0030 |
| 275-16-075 | 388-855-0075 |
| 275-16-095 | 388-855-0095 |
| 275-16-105 | 388-855-0105 |