WSR 17-03-113
(Washington Apple Health)
[Filed January 17, 2017, 1:58 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 16-20-082.
Title of Rule and Other Identifying Information: WAC 182-502-0110 Conditions of paymentMedicare coinsurance, copayments, and deductibles.
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at or directions can be obtained by calling (360) 725-1000), on February 21, 2017, at 10:00 a.m.
Date of Intended Adoption: Not sooner than February 22, 2017.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, email, fax (360) 586-9727, by 5:00 p.m. on February 21, 2017.
Assistance for Persons with Disabilities: Contact Amber Lougheed by February 17, 2017, email, (360) 725-1349, or TTY (800) 848-5429 or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is revising WAC 182-502-0110 to clarify prior authorization requirements for dual-eligible clients when their medicare benefits are exhausted. The proposed amendments also add language to clarify that timely billing requirements must be met and that the agency may do postpayment review on paid claims. The revisions do not change current policy. The WAC title is being changed to better reflect the information in the WAC section.
Reasons Supporting Proposal: See Purpose above.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Statute Being Implemented: RCW 41.05.021, 41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Katie Pounds, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1346; Implementation and Enforcement: Nancy Hite, P.O. Box 45530, Olympia, WA 98504-5530, (360) 725-1611.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has determined that the proposed filing does not impose a disproportionate cost impact on small businesses or nonprofits.
A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
January 17, 2017
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 16-13-157, filed 6/22/16, effective 7/23/16)
WAC 182-502-0110 Conditions of payment and prior authorization requirementsMedicare coinsurance, copayments, and deductibles.
(1) The following people are eligible for benefits under this section:
(a) Dual-eligible clients enrolled in categorically needy Washington apple health programs;
(b) Dual-eligible clients enrolled in medically needy Washington apple health programs; or
(c) Clients enrolled in the qualified medicare beneficiary (QMB) program.
(2) The agency pays the medicare coinsurance, copayments, and deductibles for Part A, Part B, and medicare advantage Part C for an eligible person under subsection (1) of this section:
(a) Up to the published or calculated medicaid-only rate; and
(b) If the provider accepts assignment for medicare payment.
(3) If a medicare Part A recipient has remaining lifetime reserve days, the agency pays the deductible and coinsurance amounts up to the allowed amount as calculated by the agency.
(4) If a medicare Part A recipient has exhausted lifetime reserve days during an inpatient hospital stay, the agency pays the deductible and coinsurance amounts up to the agency-calculated allowed amount minus any payment made by medicare, and any payment made by the agency, up to the outlier threshold. Once the outlier threshold is reached, the agency pays according to WAC 182-550-3700.
(5) If medicare and medicaid cover the service, the agency pays the deductible and coinsurance up to medicare or medicaid's allowed amount, whichever is less.
(6) If only medicare covers the service, the agency pays the deductible and coinsurance up to the agency's allowed amount established for a QMB client, and at zero for a non-QMB client.
(7) If a client exhausts medicare benefits, the agency pays for medicaid-covered services under Title 182 WAC and the agency's billing instructions.
(8) When medicaid requires prior authorization for a service covered by both medicare and medicaid:
(a) Medicaid does not require prior authorization when the client's medicare benefit is not exhausted.
(b) Medicaid does require prior authorization when the client's medicare benefit is exhausted. See also WAC 182-501-0050(5).
(9) Providers must meet the timely billing requirements under WAC 182-502-0150 in order to be paid for services.
(10) Payment for services is subject to postpayment review.