Purpose: The HIV client services program of the Department of Health is revising chapter 246-130 WAC to achieve two goals:

     1. Establish rules as authorized under RCW 43.70.670.

     2. Update and clarify the language of the WAC.

     Citation of Existing Rules Affected by this Order: Repealing WAC 246-130-028; and amending WAC 246-130-001, 246-130-010, 246-130-020, 246-130-030, 246-130-040, 246-130-045, 246-130-060, 246-130-080, and 246-130-090.

     Statutory Authority for Adoption: RCW 43.70.670.

      Adopted under notice filed as WSR 05-18-072 on September 7, 1005 [2005].

     Changes Other than Editing from Proposed to Adopted Version: Based on comments from key stakeholders, one definition and a reference to Basic Health were eliminated and the name of the Medicare PDP program was changed.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 8, Repealed 1.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 8, Repealed 1.

     Date Adopted: October 18, 2005.

Mary C. Selecky

Secretary

OTS-8286.4

     The early intervention program provides treatment of HIV infection to eligible clients based on available funds. The department provides these early intervention services to improve ((the)) public health by treating people living with HIV, its complications, and side effects of HIV treatment, and in order to decrease the risk of clients with HIV infecting others. Information on how to contact this program is in WAC 246-130-090.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-001, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-001, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-001, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-010, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-010, filed 10/26/87.]

     (1) "AIDS" means acquired immunodeficiency syndrome.

     (2) "Applicant" means a person applying for early intervention program services.

     (3) "Benefits manager" means:

     (a) The pharmacy benefits manager contracted with the department to provide prescription drug claim processing and formulary management services; or

     (b) The insurance benefits manager contracted with the department to provide insurance premium assistance through the HIV insurance program and the Medicare premium assistance program.

     (4) "Client" means a person ((determined to be)) who the department determines is currently eligible ((by the department)) for early intervention program services.

     (((4))) (5) "Department" means the Washington state department of health.

     (((5))) (6) "Early intervention program services" means medically necessary treatment and services that reduce the rate of progression of HIV infection and HIV transmission. This includes behavioral risk reduction interventions. See WAC 246-130-020 for details.

     (((6))) (7) "Federal poverty level" means the official income level for poverty released by the federal government each year in February.

     (((7))) (8) "Formulary" means the list of prescription drugs that the early intervention program will pay for. To obtain a copy of that list, see WAC 246-130-090.

     (((8))) (9) "HIV" means human immunodeficiency virus as defined in RCW 70.24.017(7).

     (10) "HIV insurance program" means the program that provides health insurance coverage for individuals with HIV who are not eligible for medical assistance programs from the department of social and health services. Medical assistance program is defined in RCW 74.9.010(8). Individuals must meet the eligibility requirements established by the department.

     (((9) "Medical assistance administration (MAA)" means the part of the department of social and health services responsible for operating the state's Medicaid and related medical programs.

     (10))) (11) "Medicare premium assistance" means the program that pays premiums, co-payments and deductibles for department clients receiving Medicare and enrolled in the prescription drug program.

     (12) "Provider" means a health care professional contracted by the department to supply ((pharmaceutical,)) medical, dental, or laboratory services to a client.

     (((11))) (13) "Schedule of services" means the department's list of medical, dental, and laboratory services covered by its early intervention program. To obtain a copy of that list, see WAC 246-130-090.

     (((12))) (14) "Standard of care" means treatment for HIV that is commonly accepted by the local medical community.

     (((13))) (15) "Steering committee" means the department's ((HIV)) early intervention steering committee. This advisory committee serves at the pleasure of the ((DOH)) department secretary ((per)) in accordance with RCW 43.70.040(2)((,)). The committee consists of Washington state residents living with HIV ((and)), HIV medical experts, and representatives from community organizations((, and)). The steering committee advises the department on its early intervention program. ((Its bylaws are available from the department per WAC 246-130-090.))

[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-010, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-010, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), § 246-130-010, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-010, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-015, filed 8/17/90, effective 9/17/90.]

     (1) The department decides what specific medical, laboratory, dental, ((and)) prescription medication and insurance services to cover after actively consulting with its steering committee and considering:

     (a) Support of the steering committee((, which represents clients and local medical HIV/AIDS communities));

     (b) FDA approval ((())for prescription medications(()));

     (c) ((Recognition)) Standard of care recognized by the medical community ((as a standard of care));

     (d) Effectiveness in treatment for HIV, complications of HIV, side effects of current treatments for HIV or support for HIV treatment adherence; and

     (e) Relative cost of services.

     (2) The early intervention program services described in this section are available to all clients, unless they receive those services from other sources. Specific services of this section are available for a client only when medically necessary to treat HIV and associated diseases, complications of treating HIV, or support for HIV treatment adherence.

     (3) Specific covered medical, laboratory, and dental services are listed in the department's "schedule of services."

     (4) Prescription drugs covered are listed in the department's "early intervention drug formulary."

     (5) ((Covered health)) HIV insurance program includes:

     (a) Premium payment((, including COBRA premiums)) or assistance as authorized in RCW 43.70.670;

     (b) Deductible payment up to ((five hundred dollars per)) a limit determined by the early intervention program within a twelve-month period; and

     (c) Co-pay payment for third-party insurance((, except basic health plan,)) as follows:

     (i) The percentage of prescription medication costs covered by the department and not covered by third-party insurers; and

     (ii) Fixed dollar co-pay required by a client's third-party insurance plan for prescription medication covered by the early intervention program.

     (((d) For basic health plan enrollees, the department pays the percentage of prescription medication expenses not covered by the basic health plan but covered by the department's early intervention program formulary.))

     (6) Medicare premium assistance will pay premiums, co-payment and deductibles for early intervention program clients on Medicare who request assistance for the prescription drug program.

     (7) The department may also coordinate other services to treat HIV and AIDS. These are available as funding and contracting permit. For example, as of July 1, 2000, the department may pay toward the spend-down for ((MAA)) medically needy (MN) clients who are also ((DOH)) early intervention program clients((, up to one thousand one hundred dollars per month)).

     (((7))) (8) The early intervention program will provide written notification to clients, providers, and the steering committee at least thirty days in advance of any reduction in service or payments.

     (9) You may contact the department per WAC 246-130-090 to make comments on service coverage or to receive information.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-020, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-020, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-020, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-020, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-020, filed 10/26/87.]

     (1) The department pays a provider((s)) or benefits manager who contracts with the department for services described in WAC 246-130-020.

     (a) The department will only pay for services delivered by a contracted provider or benefits manager.

     (b) ((Services must be billed within one hundred eighty days of being provided.

     (2))) A provider or benefits manager must bill the department according to the procedure and terms of the contract.

     (c) The department only pays for covered, medically necessary early intervention program services delivered to clients who are eligible under WAC 246-130-040.

     (((3))) (2) Payment of services depends on availability of federal and state funds. The department will not deny payment of any individual claim for funding availability unless the department denies an entire class of claims, or an entire program.

     (((a) Providers and clients will receive written notice of any limitation or reduction in coverage or payment that results from loss of federal or state funding at least thirty days in advance.

     (b) If the department denies or reduces payment for any class of claims or program, it must only show that it made a good faith effort to mail written notice to all providers and clients.

     (4))) (3) A provider((s)) or benefits manager who disputes a payment may do so through the contracts process((. See)) specified in WAC 246-130-080(3).

     (((5) Providers must bill the department per terms of the contract between the provider and department.

     (6))) (4) The department is payer of last resort.

     (a) A provider((s)) or benefits manager must bill all other third-party sources prior to billing the department for covered services((,)); and

     (b) A provider((s)) or benefits manager must reimburse the department for any funds paid by the department, which ((are payable)) were actually reimbursed by other sources.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-030, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-030, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), § 246-130-030, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-030, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-030, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-030, filed 10/26/87.]

     (2) An applicant is eligible for twelve months of early intervention program services ((when)) beginning the first of the month that the applicant's completed application was postmarked.

     (3) The department requires the following documentation:

     (a) ((The applicant has)) A medical diagnosis of HIV (((the department may require a doctor's diagnosis)));

     (b) ((The applicant has)) A Washington state address ((and intends to stay in Washington state));

     (c) ((The applicant or his/her designated representative has submitted truthful information on the department's application form to the department;

     (d) The applicant has monthly)) Verification of income, ((averaged over twelve months,)) that is equal to or less than the limit set by ((DOH in consultation with)) the early intervention program ((steering committee. For example: In 2000, that limit was three hundred seventy percent of Federal Poverty Level for one person ($2,575) per month. The department shall announce and seek public comment on proposed changes to the income limit)). Income includes:

     (i) Wages, salary, overtime, tips, and bonuses;

     (ii) Social Security, trust funds for disability, or other disability insurance payments;

     (iii) Unemployment benefits;

     (iv) Veteran's Administration benefits;

     (v) Lump sum payments of gifts, cash inheritance, property, lottery winnings, worker's compensation for lost income, or severance pay;

     (vi) Private pensions, annuities, or royalties; and

     (vii) Investment dividends.

     (((e))) (4) The ((applicant has)) department also considers the following when determining client eligibility:

     (a) Client resources: A client must have current resources of less than ((ten thousand dollars)) or equal to the limit set by the early intervention program. Resources include trust funds, and any other financial resources available to the applicant. The department does not count the following as resources:

     (i) One home, defined as real property owned by the client as his or her principal place of residence in Washington state, together with surrounding property not to exceed five acres;

     (ii) Commercial property, or property used for producing income, up to the first twenty thousand dollars of value;

     (iii) Household furnishings;

     (iv) One automobile; or

     (v) Pensions and other Internal Revenue Service designated retirement accounts; or

     (((f) The applicant is not currently eligible for or cannot access)) (vi) Burial plots or prepaid funeral arrangements.

     (b) Client ineligibility for medical benefits ((from)) through the department of social and health services((; and

     (g) The applicant is not currently an inmate of any correctional institute or jail or will not be when their application is approved.

     (2) Periods of eligibility caused by false information may cause the department to:

     (a) Disenroll a client from the department's early intervention program; and

     (b) Recover funds paid by the department during periods of false eligibility)). If a client is eligible for medical benefits through the department of social and health services, he or she may not qualify for the early intervention program, except when the department is coordinating other services as specified in WAC 246-130-020(6).

     (5) Individuals transitioning from any correctional institute are eligible for service that will assist them to access medication once they are released from the facility.

     (6) Refer to the HIV client services web page through DOH WEB (A-Z) at www.doh.wa.gov.

[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-040, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-040, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. 92-02-018 (Order 224), § 246-130-040, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-040, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-040, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-040, filed 10/26/87.]

     (2) Clients who do not notify the department of changes may be disenrolled and required to repay the funds spent on their services.

     (3) Clients may be disenrolled from the program if they provide false information.

[]

     (1))) Applicant and client information supplied to the ((department)) early intervention program is confidential. The early intervention program follows all applicable state and federal laws regarding the exchange of medical information.

     (((2) Applicants must provide medical and financial information at the department's request, including:

     (a) Sources and amounts of all income and resources;

     (b) Evidence that all resources or entitlements available to an applicant were accessed before that applicant applied for or received early intervention program services; and

     (c) Other medical or financial information.

     (3) Clients must notify the department of medical or financial changes that affect their eligibility within twenty days of the change. Clients who do not notify the department of medical or financial changes must pay back to the department funds provided during the period of ineligibility caused by those changes.))

[Statutory Authority: RCW 43.70.040 and 43.70.120. 00-19-117, § 246-130-060, filed 9/20/00, effective 10/21/00; 95-23-018, § 246-130-060, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-130-060, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. 90-17-087 (Order 071), § 248-168-060, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. 87-22-012 (Order 2549), § 248-168-060, filed 10/26/87.]

     (1) Chapter 246-10 WAC details the ((adjudicated proceeding)) adjudication process for matters involving receipt of benefits. The department will provide information on the cause for denied benefits, how a proceeding may be requested, the forms necessary to request a proceeding and information on required time frames.

     (2) Applicants and clients may not appeal the department's denial or limitations when the department ((closes)) discontinues or limits an early intervention program service ((due)) to either funding availability or federal or state law or rule changes. See WAC 246-130-030(3) for more details.

     (3) Rate and payment disputes between a provider((s)) or benefits manager and the department are handled by contract.

     (4) Clients of any other public agency must use that agency's process to resolve eligibility or other disputes regarding that agency. ((MAA's fair hearings process is described in chapter 388-08 WAC.))

[Statutory Authority: RCW 43.70.040. and RCW 43.70.120. 00-19-117, § 246-130-080, filed 9/20/00, effective 10/21/00.]

     Department of Health

     Client Services

     P.O. Box 47841

     Olympia, WA 98504-7841

     Telephone ((1-800-272-2437)) 1-877-376-9316 Option 2

     Or, visit the WEB site at www.doh.wa.gov. ((Clicking on "HIV Information" accesses information about the early intervention program.)) Locate HIV client services through the "DOH WEB (A-Z)" at www.doh.wa.gov.

[Statutory Authority: RCW 43.70.040. and RCW 43.70.120. 00-19-117, § 246-130-090, filed 9/20/00, effective 10/21/00.]

     The following section of the Washington Administrative Code is repealed:

WAC 246-130-028

What services are not available?