WSR 18-09-114 PROPOSED RULES HEALTH CARE AUTHORITY [Filed April 18, 2018, 10:33 a.m.] Original Notice. Preproposal statement of inquiry was filed as WSR 18-01-028. Title of Rule and Other Identifying Information: WAC 182-546-0150 Client eligibility for ambulance transportation and 182-546-0400 General limitations on payment for ambulance services. Hearing Location(s): On May 22, 2018, 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 https://www.hca.wa.gov/assets/program/Driving-parking-checkin-instructions.pdf, or directions can be obtained by calling 360-725-1000. Date of Intended Adoption: Not sooner than May 23, 2018. Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by May 22, 2018. 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 May 18, 2018. Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Effective January 1, 2018, the agency began covering all emergency and nonemergency ambulance services provided to apple health clients through fee-for-service, including those transports for clients enrolled in an agency-contracted managed care organization. The agency also removed all references to managed care from appropriate sections within chapter 182-546 WAC. The agency filed emergency rules, effective January 1, 2018, under WSR 18-02-023 for this change. This rule-making order is the permanent rule making. Reasons Supporting Proposal: Implementation of HB 2007 (ground emergency medical transportation-GEMT), subsection (10), Laws of 2015, 64th legislature, 2015 regular session required approval from the Centers for Medicare and Medicaid Services (CMS) before implementation. CMS approved the state plan amendment with the requirement that the agency begin paying for all ground ambulance services through fee-for-service by January 1, 2018. Rule is not necessitated by federal law, federal or state court decision. Name of Proponent: HCA, governmental. Name of Agency Personnel Responsible for Drafting: Amy Emerson, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1348; Implementation and Enforcement: Abigail Cole, P.O. Box 45510, Olympia, WA 98504-5510, 360-725-1835. 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. The updates to WAC 182-546-0150 and 182 546-0400 do not impose additional compliance costs or requirements on providers. April 18, 2018 Wendy Barcus Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-07-042, filed 3/12/14, effective 4/12/14)
WAC 182-546-0150 Client eligibility for ambulance transportation.
(1) Except for ((persons)) people in the Family Planning Only and TAKE CHARGE programs, fee-for-service clients are eligible for ambulance transportation to covered services with the following limitations:
(a) ((Persons)) People in the following Washington apple health (((WAH))) programs are eligible for ambulance services within Washington state or bordering cities only, as designated in WAC 182-501-0175:
(i) Medical care services (MCS) as described in WAC 182-508-0005;
(ii) Alien emergency medical (AEM) services as described in chapter 182-507 WAC.
(b) ((Persons)) People in the ((WAH)) apple health categorically needy/qualified medicare beneficiary (CN/QMB) and ((WAH)) apple health medically needy/qualified medicare beneficiary (MN/QMB) programs are covered by medicare and medicaid, with the payment limitations described in WAC 182-546-0400(5).
(2) ((Persons)) People enrolled in an agency-contracted managed care organization (MCO) must coordinate:
(a) Ground ambulance services through ((their designated MCO, subject to the MCO coverage and limitations)) the agency under fee-for-service, subject to the coverage and limitations within this chapter; and
(b) Air ambulance services through the agency under fee-for-service, subject to the coverage and limitations within this chapter.
(3) ((Persons)) People enrolled in the agency's primary care case management (PCCM) program are eligible for ambulance services that are emergency medical services or that are approved by the PCCM in accordance with the agency's requirements. The agency pays for covered services for these ((persons)) people according to the agency's published ((medicaid provider)) billing guides and provider ((notices)) alerts.
(4) ((Persons)) People under the Involuntary Treatment Act (ITA) are not eligible for ambulance transportation coverage outside the state of Washington. This exclusion from coverage applies to ((individuals)) people who are being detained involuntarily for mental health treatment and being transported to or from bordering cities. See also WAC 182-546-4000.
(5) See WAC 182-546-0800 and 182-546-2500 for additional limitations on out-of-state coverage and coverage for ((persons)) people with other insurance.
(6) The agency does not pay for ambulance services for jail inmates and ((persons)) people living in a correctional facility, including ((persons)) people in work-release status. See WAC 182-503-0505(5).
AMENDATORY SECTION (Amending WSR 13-16-006, filed 7/25/13, effective 8/25/13)
WAC 182-546-0400 General limitations on payment for ambulance services.
(1) In accordance with WAC 182-502-0100(8), the agency pays providers the lesser of the provider's usual and customary charges or the maximum allowable rate established by the agency. The agency's fee schedule payment for ambulance services includes a base rate or lift-off fee plus mileage.
(2) The agency:
(a) ((Does not)) Pays providers under fee-for-service for ground ambulance services provided to a client who is enrolled in an agency-contracted managed care organization (MCO). ((Payment in such cases is the responsibility of the client's agency-contracted MCO;))
(b) Pays providers under fee-for-service for air ambulance services provided to a client who is enrolled in an agency-contracted MCO.
(3) The agency does not pay providers for mileage incurred traveling to the point of pickup or any other distances traveled when the client is not on board the ambulance. The agency pays for loaded mileage only as follows:
(a) The agency pays ground ambulance providers for the actual mileage incurred for covered trips by paying from the client's point of pickup to the point of destination.
(b) The agency pays air ambulance providers for the statute miles incurred for covered trips by paying from the client's point of pickup to the point of destination.
(4) The agency does not pay for ambulance services if:
(a) The client is not transported;
(b) The client is transported but not to an appropriate treatment facility; or
(c) The client dies before the ambulance trip begins (see the single exception for ground ambulance providers at WAC 182-546-0500(2)).
(5) For clients in the categorically needy/qualified medicare beneficiary (CN/QMB) and medically needy/qualified medicare beneficiary (MN/QMB) programs, the agency's payment is as follows:
(a) If medicare covers the service, the agency ((will)) pays the lesser of:
(i) The full coinsurance and deductible amounts due, based upon medicaid's allowed amount; or
(ii) The agency's maximum allowable for that service minus the amount paid by medicare.
(b) If medicare does not cover or denies ambulance services that the agency covers according to this chapter, the agency pays its maximum allowable fee; except the agency does not pay for clients on the qualified medicare beneficiaries (QMB) only program.
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