WSR 17-19-116
PROPOSED RULES
HEALTH CARE AUTHORITY
(Washington Apple Health)
[Filed September 20, 2017, 11:04 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 17-15-036.
Title of Rule and Other Identifying Information: WAC 182-549-1100 Rural health clinicsDefinitions and 182-549-1450 Rural health clinicsGeneral payment information.
Hearing Location(s): On October 24, 2017, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, 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 www.hca.wa.gov/documents/directions_to_csp.pdf or directions can be obtained by calling 360-725-1000.
Date of Intended Adoption: Not sooner than October 25, 2017.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727.
Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, TTY 800-848-5429 or 711, email amber.lougheed@hca.wa.gov, by October 20, 2017.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending WAC 182-549-1450 Rural health clinicsGeneral payment information, to implement a new payment method that allows rural health clinics to choose to receive full encounter payments directly from a client's managed care organization. Amendments were also made to clarify the time frame for reconciliations under the current payment method. In WAC 182-549-1100 Rural health clinicsDefinitions, the definition of "enhancements" is being amended to align with the new payment option and to clarify that supplemental payments are enhancements.
Reasons Supporting Proposal: The revisions regarding the new payment method in WAC 182-549-1450 are necessary to comply with SSB 5883, 65th legislature, 2017 3rd sp. sess., section 213 (1)(II). For other revisions, see Purpose above.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160, SSB 5883, 65th legislature, 2017 3rd sp. sess., section 213 (1)(II).
Statute Being Implemented: RCW 41.05.021, 41.05.160, SSB 5883, 65th legislature, 2017 3rd sp. sess., section 213 (1)(II).
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: Michaela Snook, P.O. Box 45500, Olympia, WA 98504-5500, 360-725-0917.
A school district fiscal impact statement is not required under RCW 28A.305.135.
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.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. This rule does not impose compliance costs on businesses. The new payment method is optional for rural health clinics (RHC) and complies with SSB 5883, 65th legislature, 2017 3rd sp. sess., section 213 (1)(II). The addition of a timeline to complete reconciliations informs RHCs that they must be done timely, but it is not creating new or additional requirements. Reconciliations will be done by the agency or RHC.
September 20, 2017
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-11-008, filed 5/7/15, effective 6/7/15)
WAC 182-549-1100 Rural health clinicsDefinitions.
This section contains definitions of words and phrases that apply to this chapter. Unless defined in this chapter or chapter 182-500 WAC, the definitions found in the Webster's New World Dictionary apply.
"APM index" - The alternative payment methodology (APM) is used to update APM encounter payment rates on an annual basis. The APM index is a measure of input price changes experienced by Washington's federally qualified health center (FQHC) and rural health clinic (RHC) providers.
"Base year" - The year that is used as the benchmark in measuring a clinic's total reasonable costs for establishing base encounter rates.
"Encounter" - A face-to-face visit between a client and a qualified rural health clinic (RHC) provider (e.g., a physician, physician's assistant, or advanced registered nurse practitioner) who exercises independent judgment when providing services that qualify for an encounter rate.
"Encounter rate" - A cost-based, facility-specific rate for covered RHC services, paid to a rural health clinic for each valid encounter it bills.
"Enhancements (also called managed care enhancements or supplemental payments)" - A monthly amount paid ((to RHCs)) for each client enrolled with a managed care organization (MCO). MCOs may contract with RHCs to provide services under managed care programs. RHCs receive enhancements from the medicaid agency in addition to the negotiated payments they receive from the MCOs for services provided to enrollees.
"Fee-for-service" - A payment method the agency uses to pay providers for covered medical services provided to clients enrolled in the Title XIX (medicaid) program or the Title XXI (CHIP) program, except those services provided under the agency's prepaid managed care organizations or those services that qualify for an encounter payment.
"Interim rate" - The rate established by the agency to pay a rural health clinic for covered RHC services prior to the establishment of a permanent rate for that facility.
"Medicare cost report" - The cost report is a statement of costs and provider utilization that occurred during the time period covered by the cost report. RHCs must complete and submit a report annually to medicare.
"Mobile unit" - The objects, equipment, and supplies necessary for provision of the services furnished directly by the RHC are housed in a mobile structure.
"Permanent unit" - The objects, equipment, and supplies necessary for the provision of the services furnished directly by the RHC are housed in a permanent structure.
"Rebasing" - The process of recalculating encounter rates using actual cost report data.
"Rural area" - An area that is not delineated as an urbanized area by the Bureau of the Consensus.
"Rural health clinic (RHC)" - A clinic, as defined in 42 C.F.R. 405.2401(b), that is primarily engaged in providing RHC services and is:
• Located in a rural area designated as a shortage area as defined under 42 C.F.R. 491.2;
• Certified by medicare as an RHC in accordance with applicable federal requirements; and
• Not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases.
"Rural health clinic (RHC) services" - Outpatient or ambulatory care of the nature typically provided in a physician's office or outpatient clinic or similar setting, including specified types of diagnostic examination, laboratory services, and emergency treatments. The specific list of services which must be made available by the clinic can be found under 42 C.F.R. Part 491.9.
AMENDATORY SECTION (Amending WSR 17-12-016, filed 5/30/17, effective 7/1/17)
WAC 182-549-1450 Rural health clinicsGeneral payment information.
(1) The medicaid agency pays for one encounter, per client, per day except in the following circumstances:
(a) The visits occur with different health care professionals with different specialties; or
(b) There are separate visits with unrelated diagnoses.
(2) Rural health clinic (RHC) services and supplies incidental to the provider's services are included in the encounter rate payment.
(3) ((Payments)) The agency pays for non-RHC services provided in an RHC ((are made)) on a fee-for-service basis using the agency's published fee schedules. Non-RHC services are subject to the coverage guidelines and limitations listed in chapters 182-500 through 182-557 WAC.
(4) For clients enrolled with a managed care organization (MCO), covered RHC services are paid for by ((that plan)) the MCO.
(5) For clients enrolled with ((an MCO, the agency pays each RHC a supplemental payment in addition to the amounts paid by the)) MCOs, the RHC receives an encounter rate using either the method described in (a) or (b) of this subsection.
(a) The agency makes supplemental payments, called enhancements, to the MCOs who distribute them to the RHCs. These payments are in addition to the amounts paid to the RHC by the MCO as described in subsection (4) of this section. The supplemental payments((, called enhancements,)) are paid in amounts necessary to ensure ((compliance)) that the RHC receives the full encounter rate to comply with 42 U.S.C. 1396a (bb)(5)(A).
(((a))) (i) The RHCs receive ((an)) a monthly enhancement payment ((each month)) for each managed care client assigned to them by an MCO.
(((b))) (ii) To ensure that the appropriate amounts are paid to each RHC, the agency performs an annual reconciliation of the enhancement payments. For each RHC, the agency will compare the amount actually paid to the amount determined by the following formula: (Managed care encounters times encounter rate) less fee-for-service equivalent of MCO services. If the RHC has been overpaid, the agency will recoup the appropriate amount. If the RHC has been underpaid, the agency will pay the difference. For dates of service on and after January 1, 2018, reconciliations will be conducted in the calendar year following the calendar year for which the enhancements were paid. Reconciliations will be conducted by the agency or the clinic with final review and approval by the agency. The process of settling over or under payments may extend beyond the calendar year in which the reconciliations were conducted.
(b) Effective January 1, 2018, instead of distributing monthly enhancement payments to the RHCs, MCOs will pay the full encounter rate directly to participating clinics for encounter-eligible services.
(i) RHC participation in this option is voluntary. The RHC must notify the agency in writing whether it will participate or not by no later than November 1st prior to the year of participation.
(ii) The agency performs an annual reconciliation with the MCO as outlined in the MCO contract. Reconciliations ensure appropriate amounts are paid to each RHC and that MCOs are not put at risk for, or have any right to, the enhancement portion of the claim. If an MCO has been overpaid, the agency will recoup the appropriate amount. If an MCO has been underpaid, the agency will pay the difference.
(iii) RHCs participating in the revised alternative payment method (APM) as described in WAC 182-549-1400(8) will not be eligible to receive encounter payments directly from MCOs under this section.
(6) Only those services provided to clients enrolled in the Title XIX (medicaid) program or the Title XXI (CHIP) program are eligible for encounter or enhancement payments. The agency does not pay the encounter rate or the enhancement rate for services provided to clients in state-only medical programs. Services provided to clients in state-only medical programs are considered fee-for-service, regardless of the type of service performed.