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

     Purpose: Upon order of the governor, the health care authority (HCA) was required to reduce its budget expenditures for fiscal year 2011 by 6.3 percent. This cost-saving measure was implemented as part of this mandated reduction and to bring HCA's payment methodology for qualified medicare beneficiary (QMB) clients into alignment with the payment formula established in WAC 182-502-0110 for medicare/medicaid dual-eligible QMB clients.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-517-0320.

     Statutory Authority for Adoption: RCW 41.05.021.

     Other Authority: 42 U.S.C. § 1396a (n)(2).

      Adopted under notice filed as WSR 12-01-127 on December 21, 2011.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

     Date Adopted: January 25, 2012.

Kevin M. Sullivan

Rules Coordinator

OTS-4540.2

AMENDATORY SECTION(Amending WSR 07-15-032, filed 7/12/07, effective 8/12/07)

WAC 388-517-0320   Medicare savings and state-funded medicare buy-in programs cover some client costs.   (1) For qualified medicare beneficiary (QMB) clients, the ((department)) agency pays((:

     (a) Medicare Part A premiums (if any);

     (b) Medicare Part B premiums;

     (c) Coinsurance, deductibles, and copayments for medicare Part A, Part B, and medicare advantage Part C with the following conditions:

     (i) Only the Part A and Part B deductible, coinsurance, and copayments up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110), if the service is covered by medicare and medicaid.

     (ii) Only the deductible, coinsurance, and copayments up to the medicare allowed amount if the service is covered only by medicare.

     (d) Copayments for QMB-eligible clients enrolled in medicare advantage Part C up to the medicare or medicaid allowed amount whichever is less (WAC 388-502-0110).

     (e) QMB Part A and/or Part B premiums the first of the month following the month the QMB eligibility is determined)) medicare Part A premiums (if any) and medicare Part B premiums the first of the month following the month the QMB eligibility is determined. The agency pays, in accordance with WAC 182-502-0110, medicare coinsurance, deductibles, and copayments for medicare Part A, Part B and medicare advantage Part C.

     (2) For specified low-income medicare beneficiary (SLMB) clients, the ((department)) agency pays medicare Part B premiums effective up to three months prior to the certification period if eligible for those months. No other payments are made for SLMBs. For clients eligible for both SLMB and medicaid, the agency pays medicare Part B premiums and other medical costs in accordance with WAC 182-502-0110.

     (3) For qualified individual (QI-1) clients, the ((department)) agency pays medicare Part B premiums effective up to three months prior to the certification period if eligible for those months unless:

     (a) The client receives medicaid categorically needy (CN) or medically needy (MN) benefits; and/or

     (b) The ((department's)) agency's annual federal funding allotment is spent. The ((department)) agency resumes QI-1 benefit payments the beginning of the next calendar year.

     (4) For qualified disabled working individual (QDWI) clients, the ((department)) agency pays medicare Part A premiums effective up to three months prior to the certification period if eligible for those months. The ((department)) agency stops paying medicare Part A premiums if the client begins to receive CN or MN medicaid.

     (5) For state-funded medicare buy-in program clients, the ((department)) agency pays((:

     (a) Medicare Part B premiums; and

     (b) Only the Part A and B co-insurance, deductibles, and copayments up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110), if the service is covered by medicare and medicaid.

     (6) For the dual-eligible client, (a client receiving both medicare and CN or MN medical coverage) the department pays as follows:

     (a) If the service is covered by medicare and medicaid, medicaid pays only the deductible, and coinsurance up to the medicare or medicaid allowed amount, whichever is less (WAC 388-502-0110); and

     (b) Copayments for medicare advantage Part C up to the medicare or medicaid allowed copayment amount, whichever is less (WAC 388-502-0110);

     (c) If no medicaid rate exists, the department will deny payment unless the client is also QMB then refer to section (1) above)), in accordance with WAC 182-502-0110, medicare Part B premiums. Cost sharing for medicare deductibles, copayments and coinsurance is paid by the categorically needy (CN) or medically needy (MN) medicaid program.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530 and 42 U.S.C. Section 1396a. 07-15-032, § 388-517-0320, filed 7/12/07, effective 8/12/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). 05-14-125, § 388-517-0320, filed 7/1/05, effective 8/1/05.]

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