WSR 06-08-046

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed March 30, 2006, 1:56 p.m. , effective April 30, 2006 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The rules add language to clarify, update, and ensure clear and consistent policies for the certified public expenditure (CPE) program, the disproportional share hospital (DSH) program, and the trauma program; add an additional requirement that peer group E hospitals are not eligible for certain DSH programs; add a new section that identifies the criteria for considering a hospital's eligibility for the psychiatric indigent inpatient disproportionate share hospital (PIIDSH) payment and that PIIDSH payments are determined using a prospective payment method; replace "medical assistance administration" and "MAA" with "the department"; add language that requires hospitals to annually submit a copy of their charity and bad debt policy; repeal WAC 388-550-6800 and provide updated language in new section WAC 388-550-5425 regarding the upper payment limit (UPL) for inpatient hospital services; and delete language that allows payment through the ratio of costs-to-charges (RCC) payment method when the department determines that the psychiatric services provided to a client eligible under a state-only administered program qualify for a special exemption.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-550-6800; and amending WAC 388-550-3300, 388-550-4300, 388-550-4600, 388-550-4650, 388-550-4900, 388-550-5000, 388-550-5150, 388-550-5200, 388-550-5210, 388-550-5220, 388-550-5400, and 388-550-5450.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.500.

Adopted under notice filed as WSR 06-05-103 and 06-05-104 on February 14, 2006.

A final cost-benefit analysis is available by contacting Ayuni Wimpee, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1835, fax (360) 753-9152, e-mail wimpeah@dshs.wa.gov. (No changes were made. The preliminary cost-benefit analysis will be final.)

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.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 2, Amended 12, 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 2, Amended 12, Repealed 1.

Date Adopted: March 28, 2006.

Andy Fernando, Manager

Rules and Policies Assistance Unit

3638.3
AMENDATORY SECTION(Amending WSR 05-12-132, filed 6/1/05, effective 7/1/05)

WAC 388-550-3300   Hospital peer groups and cost caps.   (1) For rate-setting purposes the department groups hospitals into peer groups and establishes cost caps for each peer group. The department sets hospital reimbursement rates at levels that recognize the costs of reasonable, efficient, and effective providers.

(2) The six ((medical assistance administration (MAA))) hospital peer groups are:

(a) Group A, rural hospitals;

(b) Group B, urban hospitals without medical education programs;

(c) Group C, urban hospitals with medical education program;

(d) Group D, specialty hospitals or other hospitals not easily assignable to the other five groups;

(e) Group E, public hospitals participating in the "full cost" public hospital certified public expenditure (CPE) program; and

(f) Group F, critical access hospitals.

(3) ((MAA)) The department uses a cost cap at the seventieth percentile for hospitals in peer groups B and C. All other peer groups are exempt from the cost cap((.))s for the following reasons:

(a) ((MAA exempts)) Peer group A hospitals ((from the cost cap)) because they are paid under the ratio of costs-to-charges (RCC) methodology for Medicaid claims.

(b) ((MAA exempts)) Peer group D hospitals ((from the cost cap)) because they are specialty hospitals without a common peer group on which to base comparisons.

(c) ((MAA exempts)) Peer group E hospitals ((from the cost cap)) because they are paid under the ((ratio of costs-to-charges ())RCC(())) methodology for ((Medicaid and GAU)) inpatient claims.

(d) ((MAA exempts)) Peer group F hospitals ((from the cost cap)) because they are paid under the departmental weighted costs-to-charges (DWCC) methodology for Medicaid claims.

(4) ((MAA)) The department calculates ((a peer group's)) cost caps for peer groups B and C based on the hospitals' base period costs after subtracting:

(a) Indirect medical education costs, in accordance with WAC 388-550-3250(2), from the aggregate operating and capital costs of each hospital in the peer group; and

(b) The cost of outlier cases from the aggregate costs in accordance with WAC 388-550-3350(1).

(5) ((MAA)) The department uses the lesser of each individual hospital's calculated aggregate cost or the peer group's seventieth percentile cost cap as the base amount in calculating the individual hospital's adjusted cost-based conversion factor. After the peer group cost cap is calculated, ((MAA)) the department adds back to the individual hospital's base amount its indirect medical education costs and appropriate outlier costs, as determined in WAC 388-550-3350(2).

(6) In cases where corrections or changes in an individual hospital's base-year cost or peer group assignment occur after peer group cost caps are calculated, ((MAA)) the department updates the peer group cost caps involved only if the change in the individual hospital's base-year costs or peer group assignment will result in a five percent or greater change in the seventieth percentile of costs calculated for either its previous peer group category, its new peer group category, or both.

[Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, 388-550-3300, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. 01-16-142, 388-550-3300, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, 388-550-3300, filed 12/18/97, effective 1/18/98.]


AMENDATORY SECTION(Amending WSR 05-12-132, filed 6/1/05, effective 7/1/05)

WAC 388-550-4300   Hospitals and units exempt from the DRG payment method.   (1) Except when otherwise specified, inpatient services provided by hospitals and units that are exempt from the diagnosis-related group (DRG) payment method are reimbursed under the ratio of costs-to-charges (RCC) payment method described in WAC 388-550-4500.

(2) Subject to the restrictions and limitations listed in this section, the department exempts the following hospitals and units from the DRG payment method for inpatient services provided to Medicaid-eligible clients:

(a) Peer group A hospitals, as described in WAC 388-550-3300(2). Exception: Inpatient services provided to clients eligible under the following programs are reimbursed through the DRG payment method:

(i) General assistance programs; and

(ii) Other state-only administered programs.

(b) Peer group E hospitals, as described in WAC 388-550-3300(2). See WAC 388-550-4650 for how the department calculates payment to Peer group E hospitals.

(c) Peer group F hospitals (critical access hospitals).

(d) Rehabilitation units when the services are provided in ((medical assistance administration (MAA))) department-approved acute physical medicine and rehabilitation (acute PM&R) hospitals and designated distinct rehabilitation units in acute care hospitals.

((MAA)) The department uses the same criteria as the Medicare program to identify exempt rehabilitation hospitals and designated distinct rehabilitation units. Exception: Inpatient rehabilitation services provided to clients eligible under the following programs are covered and reimbursed through the DRG payment method:

(i) General assistance programs; and

(ii) Other state-only administered programs.

(e) Out-of-state hospitals excluding hospitals located in designated bordering cities as described in WAC 388-501-0175. Inpatient services provided in out-of-state hospitals to clients eligible under the following programs are not covered or reimbursed by the department:

(i) General assistance programs; and

(ii) Other state-only administered programs.

(f) Military hospitals when no other specific arrangements have been made with the department. Military hospitals may individually elect or arrange for one of the following payment methods in lieu of the RCC payment method:

(i) A negotiated per diem rate; or

(ii) DRG.

(g) Nonstate-owned specifically identified psychiatric hospitals and designated hospitals with Medicare certified distinct psychiatric units. The department uses the same criteria as the Medicare program to identify exempt psychiatric hospitals and distinct psychiatric units of hospitals.

(i) Inpatient psychiatric services provided to clients eligible under the following programs are reimbursed through the DRG payment method:

(A) General assistance programs; and

(B) Other state-only administered programs.

(ii) ((If the department determines that the psychiatric services provided to a client eligible under a program listed in subsection (2)(g)(i) of this section qualify for a special exemption, the services may be reimbursed by using the ratio of costs-to-charges (RCC) payment method.

(iii))) Regional support networks (RSNs) that arrange to reimburse nonstate-owned psychiatric hospitals and designated distinct psychiatric units of hospitals directly, may use the department's payment methods or contract with the hospitals to reimburse using different methods. Claims not paid directly through an RSN are paid through the department's ((MMIS)) payment system.

(3) The department limits inpatient hospital stays that are exempt from the DRG payment method and identified in subsection (2) of this section to the number of days established at the seventy-fifth percentile in the current edition of the publication, "Length of Stay by Diagnosis and Operation, Western Region," unless the stay is:

(a) Approved for a specific number of days by the department, or for psychiatric inpatient stays, by the regional support network (RSN);

(b) For chemical dependency treatment which is subject to WAC 388-550-1100; or

(c) For detoxification of acute alcohol or other drug intoxication.

(4) If subsection (3)(c) of this section applies to an eligible client, the department will:

(a) Pay for three-day detoxification services for an acute alcoholic condition; or

(b) Pay for five-day detoxification services for acute drug addiction when the services are directly related to detoxification; and

(c) Extend the three- and five-day limitations for up to six additional days if either of the following is invoked on a client under care in a hospital:

(i) Petition for commitment to chemical dependency treatment; or

(ii) Temporary order for chemical dependency treatment.

[Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, 388-550-4300, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. 01-16-142, 388-550-4300, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, 388-550-4300, filed 12/18/97, effective 1/18/98.]


AMENDATORY SECTION(Amending WSR 05-12-132, filed 6/1/05, effective 7/1/05)

WAC 388-550-4600   Hospital selective contracting program.   (1) The department designates selective contracting areas (SCA) in which hospitals participate in competitive bidding to provide hospital services to Medicaid clients. Selective contracting areas are based on historical patterns of hospital use by Medicaid clients.

(2) The department requires Medicaid clients in a selective contracting area obtain their elective (nonemergent) inpatient hospital services from participating or exempt hospitals in the SCA. Elective (nonemergent) inpatient hospital services provided by nonparticipating hospitals in an SCA shall not be reimbursed by the department, except as provided in WAC 388-550-4700.

(3) The department exempts from the selective contracting program those hospitals that are:

(a) In an SCA but designated by the department as remote. The department designates hospitals as remote((, hospitals meeting)) when they meet the following criteria:

(i) Located more than ten miles from the nearest hospital in the SCA;

(ii) Having fewer than seventy-five beds; and

(iii) Having fewer than five hundred Medicaid admissions in a two-year period.

(b) Owned by health maintenance organizations (HMOs) and providing inpatient services to HMO enrollees only;

(c) Children's hospitals;

(d) State psychiatric hospitals or separate (freestanding) psychiatric facilities;

(e) Out-of-state hospitals located in nonbordering cities, and out-of-state hospitals in bordering cities not designated as selective contracting areas;

(f) Peer group E hospitals; and

(g) Peer group F hospitals (critical access hospitals).

(4) ((MAA)) The department:

(a) Negotiates with selectively contracted hospitals a negotiated conversion factor (NCF) for inpatient hospital services provided to Medicaid clients.

(b) Calculates its maximum financial obligation for a Medicaid client under the hospital selective contract in the same manner as DRG payments using cost-based conversion factors (CBCFs).

(c) Applies NCFs to Medicaid clients only. (((MAA)) The department uses CBCFs in calculating payments for medical care services clients.)

[Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, 388-550-4600, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, 388-550-4600, filed 12/18/97, effective 1/18/98.]


AMENDATORY SECTION(Amending WSR 05-12-132, filed 6/1/05, effective 7/1/05)

WAC 388-550-4650   "Full cost" public hospital certified public expenditure (CPE) payment program.   (1) The ((medical assistance administration's (MAA's))) department's "full cost" public hospital certified public expenditure (CPE) payment program ((is a public hospital program that pays eligible hospitals the same amount as the Medicaid federal match portion of the "full cost" of covered medically necessary services. MAA uses the ratio of costs-to-charges methodology described in WAC 388-550-4500 to determine "full cost.")) provides payments to participating hospitals based on the "full cost" of covered medically necessary services and requires the expenditure of local funds in lieu of state funds to qualify for federal matching funds. The department's payments to participating hospitals equal the federal matching amount for allowable costs. The department uses the ratio of costs-to-charges method described in WAC 388-550-4500 to determine "full cost."

(2) Only the following facilities are reimbursed through the "full cost" public hospital CPE payment program:

(a) Public hospitals located in the state of Washington that are:

(i) Owned by public hospital districts; and

(ii) Not certified by the department of health (DOH) as a critical access hospital;

(b) Harborview Medical Center; and

(c) University of Washington Medical Center.

(3) Payments made under the CPE payment program are limited to medically necessary services provided to medical assistance clients eligible for inpatient hospital services ((provided to clients eligible under the Medicaid and general assistance-unemployable (GA-U) fee-for-service programs)).

(4) Each hospital described in subsection (2) of this section is responsible to provide certified public expenditures as the required state match for claiming federal Medicaid funds. ((Certified public expenditures cannot include federal funds or money used to match federal funds.))

(5) ((Payments made by MAA)) The department determines the actual payment for inpatient hospital services under the CPE payment program ((equal)) by:

(a) Multiplying the hospital's Medicaid RCC rate ((times allowable charges times)) by the covered charges (to determine allowable costs), then;

(b) Subtracting the client's responsibility and any third party liability (TPL) from the amount derived in (a) of this subsection, then;

(c) Multiplying the state's ((Medicaid)) federal ((match percentage)) matching assistance percentage (FMAP) by the amount derived in (b) of this subsection.

(((6) Client responsibility and third party liability as identified on the hospital claim or by MAA are deducted from the basic payment to determine MAA's actual payment for that admission.))

[Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, 388-550-4650, filed 6/1/05, effective 7/1/05.]


AMENDATORY SECTION(Amending WSR 05-12-132, filed 6/1/05, effective 7/1/05)

WAC 388-550-4900   Disproportionate share payments.   As required by section 1902 (a)(13)(A) of the Social Security Act, the ((medical assistance administration (MAA))) department gives consideration to hospitals that serve a disproportionate number of low-income clients with special needs by making a payment adjustment to eligible hospitals ((per)) in accordance with legislative direction and established prospective payment methods. ((MAA)) The department considers this adjustment a disproportionate share hospital (DSH) payment.

(1) To qualify for a DSH payment for each state fiscal year (SFY), an instate or bordering city hospital provider must submit to ((MAA)) the department, the hospital's completed and final DSH application by the due date specified in that year's application letter. ((The application due date will not be less than sixty days after MAA makes the application available.))

(2) A hospital is a disproportionate share hospital eligible for the low-income disproportionate share hospital (LIDSH) program for a specific SFY if the hospital submits a DSH application for that specific year in compliance with subsection (1) and if both the following apply:

(a) The hospital's Medicaid inpatient utilization rate (MIPUR) is at least one standard deviation above the mean Medicaid inpatient utilization rate for hospitals receiving Medicaid payments in the state, or ((its)) the hospital's low-income utilization rate (LIUR) exceeds twenty-five percent; and

(b) At least two obstetricians who have staff privileges at the hospital have agreed to provide obstetric services to eligible individuals at the hospital. For the purpose of establishing DSH eligibility, "obstetric services" is defined as routine nonemergency delivery of babies. This requirement for two obstetricians with staff privileges does not apply to a hospital:

(i) That provides inpatient services predominantly to individuals under eighteen years of age; or

(ii) That did not offer nonemergency obstetric services to the general public as of December 22, 1987, when section 1923 of the Social Security Act was enacted.

(3) For hospitals located in rural areas, "obstetrician" means any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.

(4) ((MAA)) The department may consider a hospital a disproportionate share hospital for programs other than the LIDSH program if the hospital submits a DSH application for the specific year and meets the following criteria for the year specified in the application:

(a) The hospital has a MIPUR of not less than one percent; and

(b) The hospital meets the requirement of subsection (2)(b) of this section.

(5) ((MAA)) To determine a hospital's eligibility for any DSH program, the department uses the criteria in this section and the information derived from the DSH application submitted by the hospital, subject to the following:

(a) Charity care. If the hospital's DSH application and audited financial statement for the relevant fiscal year do not agree on the amount for charity care, the department uses the lower amount claimed.

(b) Bad debt. If the hospital's DSH application does not allocate bad debt between insured and uninsured patients, the department assigns the entire amount of bad debt to insured patients.

(c) Total inpatient hospital days. If the hospital's DSH application lists a total number of inpatient hospital days that is lower than the total number in the hospital's Medicare cost report, the department uses the higher number to determine the hospital's MIPUR. The department may use the lower number to determine the hospital's MIPUR if, within ten business days of the department's written notification to the hospital of the discrepancy, the hospital submits documentation that supports the lower number of inpatient hospital days listed on the DSH application. Acceptable documentation includes, but is not limited to, a revised cost report submitted to Medicare that shows the correct data.

(6) Hospitals must submit annually to the department a copy of the hospital's charity and bad debt policy as part of the individual hospital's DSH application.

(7) The department administers the low-income disproportionate share hospital (LIDSH) program and may administer any of the following DSH programs:

(a) General assistance-unemployable disproportionate share hospital (GAUDSH);

(b) Small rural hospital assistance program disproportionate share hospital (SRHAPDSH);

(c) Small rural hospital indigent ((adult)) assistance program disproportionate share hospital (((SRHIAAPDSH))) (SRHIAPDSH);

(d) Nonrural hospital indigent ((adult)) assistance program disproportionate share hospital (((NRHIAAPDSH))) (NRHIAPDSH); ((and))

(e) Public hospital disproportionate share hospital (PHDSH); and

(f) Psychiatric indigent inpatient disproportionate share hospital (PIIDSH).

(((6) MAA)) (8) The department allows a hospital to receive any one or all of the DSH payment adjustments discussed in subsection (((5))) (7) of this section when the hospital:

(a) Meets the requirements in subsection (4) of this section; and

(b) Meets the eligibility requirements for the particular DSH payment program, as discussed in WAC 388-550-5000 through 388-550-5400.

(((7) MAA)) (9) The department ensures each hospital's total DSH payments do not exceed the individual hospital's DSH limit, defined as:

(a) The cost to the hospital of providing services to Medicaid clients, including clients served under Medicaid managed care programs;

(b) Less the amount paid by the state under the non-DSH payment provision of the state plan;

(c) Plus the cost to the hospital of providing services to uninsured patients;

(d) Less any cash payments made by uninsured clients; and

(e) Plus any adjustments required and/or authorized by federal regulation.

(((8) MAA's)) (10) The department's total annual DSH payments ((must not)) cannot exceed the state's DSH allotment for the federal fiscal year.

If the ((MAA)) department's statewide allotment is exceeded, ((MAA)) the department may adjust future DSH payments to each hospital to compensate for the amount overpaid. Adjustments will be made in the following program order:

(a) PHDSH;

(b) SRHAPDSH;

(((b) NRHIAAPDSH)) (c) NRHIAPDSH;

(((c) SRHIAAPDSH)) (d) SRHIAPDSH;

(((d))) (e) GAUDSH;

(f) PIIDSH; and

(((e))) (g) LIDSH((; and

(f) PHDSH)).

[Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, 388-550-4900, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. 04-12-044, 388-550-4900, filed 5/28/04, effective 7/1/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, 388-550-4900, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730 and 42 U.S.C. 1396r-4. 99-14-040, 388-550-4900, filed 6/30/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, 388-550-4900, filed 12/18/97, effective 1/18/98.]


AMENDATORY SECTION(Amending WSR 03-13-055, filed 6/12/03, effective 7/13/03)

WAC 388-550-5000   Payment method--LIDSH.   (1) A hospital ((serving)) that is not a peer group E hospital but serves the department's clients is eligible for a low-income disproportionate share hospital (LIDSH) payment adjustment if the hospital meets the requirements of WAC 388-550-4900(((2))) (1) through (3).

(2)((The medical assistance administration (MAA) pays)) Hospitals considered eligible under the criteria in subsection (1) of this section receive LIDSH payments. The total LIDSH payment amounts equal the funding set by the state's appropriations act for LIDSH. The amount that the state appropriates for LIDSH may vary from year to year.

(3) ((MAA)) The department distributes LIDSH payments to ((individual)) each LIDSH eligible hospital((s)) using ((the)) a prospective payment method ((for each LIDSH-eligible hospital)). ((MAA)) The department determines the standardized Medicaid inpatient utilization rate (MIPUR) by:

(a) Dividing the hospital's MIPUR by the average MIPUR of all LIDSH-eligible hospitals; then

(b) Multiplying the hospital's standardized MIPUR by the hospital's most recent DRG payment method rebased case mix index, and then by the hospital's most recent fiscal year Title XIX admissions; then

(c) Multiplying the product by an initial random base amount; and then

(d) Comparing the sum of all annual LIDSH payments to the appropriated amount. If the amounts differ, ((MAA)) the department progressively selects a new base amount by successive approximation until the sum of the LIDSH payments to hospitals equals the legislatively appropriated amount.

(4) After each applicable state fiscal year, ((MAA)) the department will not make changes to the LIDSH payment distribution that has resulted from calculations identified in subsection (3)(((c))) of this section. However, hospitals may still submit corrected DSH application data to ((MAA)) the department after June 15 and prior to July 1 of the applicable state fiscal year to correct calculation of the MIPUR or low income utilization rate (LIUR) for historical record keeping. See WAC 388-550-5550 for rules regarding public notice for changes in Medicaid payment rates for hospital services.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, 388-550-5000, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730 and 42 U.S.C. 1396r-4. 99-14-040, 388-550-5000, filed 6/30/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, 388-550-5000, filed 12/18/97, effective 1/18/98.]


REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 388-550-6800 Proportionate share payments for inpatient hospital services.
3639.4
NEW SECTION
WAC 388-550-5125   Payment method -- PIIDSH.   (1) Effective July 1, 2003, a hospital is eligible for the psychiatric indigent inpatient disproportionate share hospital (PIIDSH) payment if the hospital:

(a) Meets the criteria in WAC 388-550-4900 (2)(b) through (4)(a);

(b) Is an in-state or bordering city hospital;

(c) Provides services to clients eligible under the psychiatric indigent inpatient (PII) program. See WAC 388-865-0217 for more information regarding the PII program; and

(d) Qualifies under Section 1923(d) of the Social Security Act.

(2) The department determines the PIIDSH payment for each eligible hospital using a prospective payment method, in accordance with WAC 388-550-4800.

[]


AMENDATORY SECTION(Amending WSR 03-13-055, filed 6/12/03, effective 7/13/03)

WAC 388-550-5150   Payment method--GAUDSH.   (1) ((The medical assistance administration (MAA) considers)) A hospital is eligible for the general assistance-unemployable disproportionate share hospital (GAUDSH) payment if the hospital:

(a) Meets the criteria in WAC 388-550-4900 (2)(b) ((and)) through (4)(a);

(b) Is an in-state or ((border area)) bordering city hospital;

(c) Provides services to clients under the medical care services program; and

(d) Has a low-income utilization rate (LIUR) of one percent or more.

(2) ((MAA)) The department determines the GAUDSH payment for each eligible hospital, using a prospective payment method, in accordance with WAC 388-550-4800, except that the payment is not reduced by the additional three percent specified in WAC 388-550-4800(4).

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, 388-550-5150, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. 99-14-025, 388-550-5150, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, 388-550-5150, filed 12/18/97, effective 1/18/98.]


AMENDATORY SECTION(Amending WSR 04-12-044, filed 5/28/04, effective 7/1/04)

WAC 388-550-5200   Payment method--SRHAPDSH.   (1) The ((medical assistance administration (MAA))) department makes small rural hospital assistance program disproportionate share hospital (SRHAPDSH) payments to qualifying small rural hospitals through the disproportionate share hospital (DSH) program.

(2) To qualify for a SRHAPDSH payment, a hospital must:

(a) Not be a peer group E hospital;

(b) Meet the criteria in WAC 388-550-4900 (2)(b) ((and)) through (4)(a);

(((b))) (c) Be an in-state hospital;

(((c))) (d) Be a small rural hospital with fewer than seventy-five acute licensed beds; and

(((d))) (e) For the SRHAPDSH program year to be implemented for state fiscal year (SFY) beginning July 1, 2002, the city or town must have a nonstudent population of fifteen thousand five hundred or less.

For each subsequent SFY, the nonstudent population requirement is increased cumulatively by two percent.

(3) ((MAA)) The department pays hospitals qualifying for SRHAPDSH payments from a legislatively appropriated pool. ((MAA)) The department determines each hospital's individual SRHAPDSH payment from the total dollars in the pool using percentages established through the following prospective payment method:

(a) At the time the SRHAPDSH payment is to be made, ((MAA)) the department calculates each hospital's profitability margin based on the most recent, completed year-end data using audited financial statements from the hospital.

(b) ((MAA)) The department determines the average profitability margin for the qualifying hospitals.

(c) Any hospital with a profitability margin of less than one hundred ten percent of the average profitability margin for qualifying hospitals receives a profit factor of 1.1. All other hospitals receive a profit factor of 1.0.

(d) ((MAA)) The department:

(i) Identifies the individual hospital's most recent, completed SFY Medicaid reimbursement amounts. These amounts are based on historical data considered to be complete; then

(ii) Multiplies the Medicaid reimbursement amount by the individual hospital's assigned profit factor (1.1 or 1.0) to identify a revised Medicaid reimbursement amount; then

(iii) Divides the revised Medicaid reimbursement amount by the sum of the revised Medicaid reimbursement amounts for all qualifying hospitals during the same period.

(4) ((MAA's)) The department's SRHAPDSH payments to a hospital may not exceed one hundred percent of the projected cost of care for Medicaid clients and uninsured indigent patients for that hospital unless an exception is identified by federal regulation. ((MAA)) The department reallocates dollars as defined in the state plan.

[Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. 04-12-044, 388-550-5200, filed 5/28/04, effective 7/1/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, 388-550-5200, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. 99-14-025, 388-550-5200, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, 388-550-5200, filed 12/18/97, effective 1/18/98.]


AMENDATORY SECTION(Amending WSR 05-12-132, filed 6/1/05, effective 7/1/05)

WAC 388-550-5210   Payment method -- ((SRHIAAPDSH))SRHIAPDSH.   (1) The ((medical assistance administration (MAA))) department makes small rural hospital indigent ((adult)) assistance program disproportionate share hospital (((SRHIAAPDSH))) (SRHIAPDSH) payments to qualifying small rural hospitals through the disproportionate share hospital (DSH) program.

(2) To qualify for an ((SRHIAAPDSH)) SRHIAPDSH payment, a hospital must:

(a) Not be a peer group E hospital;

(b) Meet the criteria in WAC 388-550-4900 (2)(b) ((and)) through (4)(a);

(((b))) (c) Be an in-state hospital that provided charity services to clients during the most recent, completed fiscal year;

(((c))) (d) Be a small rural hospital with fewer than seventy-five acute licensed beds; and

(((d))) (e) For state fiscal year (SFY) beginning July 1, 2003, be located in a city or town that has a nonstudent population of fifteen thousand eight hundred ten or less. For each subsequent SFY, the nonstudent population requirement is increased cumulatively by two percent.

(3) ((MAA)) The department pays hospitals qualifying for ((SRHIAAPDSH)) SRHIAPDSH payments from a legislatively appropriated pool. ((MAA)) The department determines each hospital's individual ((SRHIAAPDSH)) SRHIAPDSH payment from the total dollars in the pool using percentages established through the following prospective payment method:

(a) At the time the ((SRHIAAPDSH)) SRHIAPDSH payment is to be made, ((MAA)) the department calculates each hospital's profitability margin based on the most recent, completed year-end data using audited financial statements from the hospital.

(b) ((MAA)) The department determines the average profitability margin for the qualifying hospitals.

(c) Any hospital with a profitability margin of less than one hundred ten percent of the average profitability margin for qualifying hospitals receives a profit factor of 1.1. All other hospitals receive a profit factor of 1.0.

(d) ((MAA)) The department:

(i) Identifies from historical data considered to be complete, each individual qualifying hospital's allowed charity charges; then

(ii) Multiplies the total allowed charity charges by the hospital's ratio of costs-to-charges (RCC), limiting the RCC to a value of 1, to determine the hospital's charity costs; then

(iii) Multiplies the hospital's charity costs by the hospital's profit factor assigned in (c) of this subsection to identify a revised cost amount; then

(iv) Determines the hospital's percentage of revised costs by dividing its revised cost amount by the sum of the revised charity cost amounts for all qualifying hospitals during the same period.

(4) ((MAA's SRHIAAPDSH)) The department's SRHIAPDSH payments to a hospital may not exceed one hundred percent of the projected cost of care for Medicaid clients and uninsured indigent patients for that hospital unless an exception is identified by federal regulation. ((MAA)) The department reallocates dollars as defined in the state plan.

[Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, 388-550-5210, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. 04-12-044, 388-550-5210, filed 5/28/04, effective 7/1/04.]


AMENDATORY SECTION(Amending WSR 05-12-132, filed 6/1/05, effective 7/1/05)

WAC 388-550-5220   Payment method -- ((NRHIAAPDSH))NRHIAPDSH.   (1) The ((medical assistance administration (MAA))) department makes nonrural hospital indigent ((adult)) assistance program disproportionate share hospital (((NRHIAAPDSH))) (NRHIAPDSH) payments to qualifying nonrural hospitals through the disproportionate share hospital (DSH) program.

(2) To qualify for an ((NRHIAAPDSH)) NRHIAPDSH payment, a hospital must:

(a) Not be a peer group E hospital;

(b) Meet the criteria in WAC 388-550-4900 (2)(b) ((and)) through (4)(a);

(((b))) (c) Be an in-state or bordering city hospital that provided charity services to clients during the most recent, completed fiscal year; and

(((c))) (d) Be a hospital that does not qualify as a small rural hospital as defined in WAC 388-550-5210.

(3) ((MAA)) The department pays hospitals qualifying for ((NRHIAAPDSH)) NRHIAPDSH payments from a legislatively appropriated pool. ((MAA)) The department determines each hospital's individual ((NRHIAAPDSH)) NRHIAPDSH payment from the total dollars in the pool using percentages established through the following prospective payment method:

(a) At the time the ((NRHIAAPDSH)) NRHIAPDSH payment is to be made, ((MAA)) the department calculates each hospital's profitability margin based on the most recent, completed year-end data using audited financial statements from the hospital.

(b) ((MAA)) The department determines the average profitability margin for the qualifying hospitals.

(c) Any hospital with a profitability margin of less than one hundred ten percent of the average profitability margin for qualifying hospitals receives a profit factor of 1.1. All other hospitals receive a profit factor of 1.0.

(d) ((MAA)) The department:

(i) Identifies from historical data considered to be complete, each individual qualifying hospital's allowed charity charges; then

(ii) Multiplies the total allowed charity charges by the hospital's ratio of costs-to-charges (RCC), limiting the RCC to a value of 1, to determine the hospital's charity costs; then

(iii) Multiplies the hospital's charity costs by the hospital's profit factor assigned in (c) of this subsection to identify a revised cost amount; then

(iv) Determines the hospital's percentage of the ((NRHIAAPDSH)) NRHIAPDSH revised costs by dividing the hospital's revised cost amount by the total charity costs for all qualifying hospitals during the same period.

(4) ((MAA's NRHIAAPDSH)) The department's NRHIAPDSH payments to a hospital may not exceed one hundred percent of the projected cost of care for Medicaid clients and uninsured indigent patients for the hospital unless an exception is identified by federal regulation. ((MAA)) The department reallocates dollars as defined in the state plan.

[Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, 388-550-5220, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. 04-12-044, 388-550-5220, filed 5/28/04, effective 7/1/04.]


AMENDATORY SECTION(Amending WSR 05-12-132, filed 6/1/05, effective 7/1/05)

WAC 388-550-5400   Payment method--PHDSH.   (1) The ((medical assistance administration's (MAA's))) department's public hospital disproportionate share hospital (PHDSH) program is a public hospital program for:

(a) Public hospitals located in the state of Washington that are:

(i) Owned by public hospital districts; and

(ii) Not certified by the department of health (DOH) as a critical access hospital;

(b) Harborview Medical Center; and

(c) University of Washington Medical Center.

(2) ((MAA)) The department pays hospitals eligible under this program a payment equal to the hospital's individual disproportionate share hospital (DSH) payment limit calculated according to WAC 388-550-4900. The resulting amount is multiplied by the federal matching assistance percentage in effect for Washington State at the time of the payment. This amount is sent to the hospital.

(3) Hospitals receiving payment ((in)) under this DSH program must certify that funds have been spent on uncompensated care at the hospital equal to or in excess of the payment amount before applying the federal matching assistance percentage. ((Certified funds cannot include federal funds or money used to match federal funds.))

[Statutory Authority: RCW 74.04.050, 74.08.090. 05-12-132, 388-550-5400, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 03-13-055, 388-550-5400, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. 99-14-025, 388-550-5400, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, 388-550-5400, filed 12/18/97, effective 1/18/98.]


NEW SECTION
WAC 388-550-5425   Upper payment limit (UPL) payments for inpatient hospital services.   (1) Each state fiscal year, in accordance with legislative direction and established prospective payment methods, the department creates an upper payment limit (UPL) payment pool that provides supplemental payments for inpatient hospital services to a hospital provider of Title XIX Medicaid services that is classified as either a:

(a) Washington state-owned or state-operated hospital; or

(b) Nonstate government-owned hospital.

(2) UPL payments for inpatient hospital services are subject to:

(a) Federal approval for federal matching funds; and

(b) A department analysis of the Medicare UPL for hospital payment.

(3) The department determines each payment year's UPL payment for inpatient hospital services by:

(a) Using the charge and payment data from the department's payment system for inpatient hospital services for the base year; and

(b) Calculating the cumulative difference between Medicare payments and Title XIX payments, including third party liability payment for all eligible hospitals during the most recent state fiscal year.

(4) UPL payments for inpatient hospital services:

(a) Are determined for participating eligible hospitals during each federal fiscal year;

(b) Are paid by the department on a periodic basis to one or more of the participating eligible hospitals; and

(c) Must be used by the receiving hospital(s) to improve health care services to low income patients.

[]


AMENDATORY SECTION(Amending WSR 04-19-113, filed 9/21/04, effective 10/22/04)

WAC 388-550-5450   Supplemental distributions to approved trauma service centers.   (1) The department's trauma care fund (TCF) is an amount legislatively appropriated to DSHS each biennium for the purpose of supplementing the ((medical assistance administration's (MAA's))) department's payments to eligible trauma service centers for providing qualified trauma services to eligible Medicaid fee-for-service clients. Claims for trauma care provided to clients enrolled in ((MAA's)) the department's managed care programs are not eligible for supplemental distributions from the TCF.

(2) Beginning with trauma services provided after June 30, 2003, ((MAA)) the department makes supplemental distributions from the TCF to qualified hospitals, subject to the provisions in this section.

(3) To qualify for supplemental distributions from the TCF, a hospital must:

(a) Be designated or recognized by the department of health (DOH) as an approved Level 1, Level 2, or Level 3 adult or pediatric trauma service center((. No distinction is made between a governmental and nongovernmental hospital));

(b) Meet the provider requirements in this section and other applicable WAC;

(c) Meet the billing requirements in this section and other applicable WAC;

(d) Submit all information ((MAA)) the department requires to ensure services are being provided; and

(e) Comply with DOH's Trauma Registry reporting requirements.

(4) Supplemental distributions from the TCF are:

(a) For qualified hospitals, determined as a percentage of a fixed amount ((for)) per quarter. Each eligible hospital's share per quarter is based on ((all of the following:

(i) The relative)) the amount paid by ((MAA)) the department to that hospital for inpatient and outpatient trauma care the hospital provides to Medicaid clients ((per)) during that quarter ((in a state fiscal year (SFY). MAA determines the amount of care provided to Medicaid clients by date of service, not date of payment; and

(ii) The amount paid by MAA to hospitals that receive transferred trauma cases, regardless of the clients' Injury Severity Score (ISS) (a summary rating system for traumatic anatomic injuries))), expressed as a percentage of the following total:

(i) The department's payments to Level 1, Level 2, and Level 3 trauma service centers for qualified Medicaid trauma cases in that quarter. The department determines the countable payment per quarter for trauma care provided to Medicaid clients based on date of service, not date of payment;

(ii) The department's payments to Level 1, Level 2, and Level 3 hospitals for trauma cases transferred in during that quarter. A Level 1, Level 2, or Level 3 hospital that receives a transferred trauma case from any lower level hospital is eligible for the enhanced payment, regardless of the client's Injury Severity Score (ISS). An ISS is a summary rating system for traumatic anatomic injuries; and

(iii) The department's payments to Level 2 and Level 3 hospitals for qualified trauma cases (those that meet or exceed the ISS criteria in subsection (4)(b) of this section) that are transferred to a higher level designated trauma service center during that quarter.

(b) Paid only for a Medicaid trauma case that meets:

(i) The ISS of thirteen or greater for an adult trauma patient (a client age fifteen or older);

(ii) The ISS of nine or greater for a pediatric trauma patient (a client younger than age fifteen); or

(iii) The conditions of subsection (4)(c) ((of this section are met)).

(c) Made to hospitals, as follows, for a trauma case that is transferred:

(i) ((The receiving hospital)) A hospital that receives the transferred trauma case qualifies for payment regardless of the ISS if the hospital is designated or recognized by DOH as an approved Level 1, Level 2, or Level 3 adult or pediatric trauma service center; ((and))

(ii) ((The transferring hospital)) A hospital that transfers the trauma case qualifies for payment only if:

(A) It is designated or recognized by DOH as an approved Level 2 or Level 3 adult or pediatric trauma service center; and

(B) The ISS requirements in (b)(i) or (b)(ii) of this subsection are met.

(iii) A hospital that DOH designates or recognizes as an approved Level 4 or Level 5 trauma service center does not qualify for supplemental distributions for transferred trauma cases, even when the transferred cases meet the ISS criteria in subsection (4)(b) of this section.

(d) Not funded by disproportionate share hospital (DSH) funds; and

(e) Not distributed by ((MAA)) the department to:

(i) Trauma service centers designated or recognized as Level 4 or Level 5; ((or))

(ii) Critical access hospitals (CAHs); or

(iii) Any hospital for follow-up surgical services related to the qualifying trauma incident but provided to the client after the client has been discharged for the initial qualifying injury.

(5) ((MAA makes supplemental distributions from the TCF to eligible hospitals as follows)) Distributions for an SFY are divided into five "quarters" and paid as follows:

(a) ((Quarterly payments are made, subject to the following:

(i))) Each quarterly distribution paid by the department from the TCF totals twenty percent of the amount designated by the department for that SFY;

(b) The first quarterly supplemental distribution from the TCF is made six months after the SFY begins;

(((ii) Each quarterly supplemental distribution from the TCF totals twenty percent of the amount designated by MAA for that SFY. If claims data for any quarter indicate an insufficient number of paid claims, MAA may adjust the percentage to allow for an equitable distribution from the TCF for that quarter. See (4)(a) of this subsection.

(b) A final supplemental distribution from the TCF is:

(ii))) (c) Subsequent quarterly payments are made approximately every four months after the first quarterly payment is made, except as described in subsection (d);

(d) The "fifth quarter" final distribution from the TCF for the same SFY is:

(i) Made one year after the end of the SFY; ((and))

(ii) Based on the SFY that the TCF designated amount relates to; and

(iii) Distributed based on each eligible hospital's percentage of the total payments made by the department to all designated trauma service centers for qualified trauma cases during the relevant fiscal year.

(6) For purposes of the supplemental distributions from the TCF, all of the following apply:

(a) ((MAA)) The department may consider a request for a claim adjustment submitted by a provider only if the request is received by ((MAA)) the department within one year from the date of the initial trauma service;

(b) ((MAA)) The department does not allow any carryover of liabilities for a supplemental distribution from the TCF after a date specified by ((MAA)) the department as the last date to make adjustments to a trauma claim for an SFY. WAC 388-502-0150(7) does not apply to TCF claims;

(c) All claims and claim adjustments are subject to federal and state audit and review requirements; and

(d) The total amount of supplemental distributions from the TCF disbursed to eligible hospitals by ((MAA)) the department in any ((current)) biennium cannot exceed the amount appropriated by the legislature for that biennium. ((MAA)) The department has the authority to take whatever actions necessary to ensure ((MAA)) the department stays within the ((current)) TCF appropriation.

[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-19-113, 388-550-5450, filed 9/21/04, effective 10/22/04.]

Washington State Code Reviser's Office