WSR 18-10-005 EMERGENCY RULES HEALTH CARE AUTHORITY [Filed April 19, 2018, 2:02 p.m., effective April 19, 2018, 2:02 p.m.] Effective Date of Rule: Immediately upon filing. Purpose: 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. Citation of Rules Affected by this Order: Amending WAC 182-546-0150 and 182-546-0400. Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule. Reasons for this Finding: In order for the agency to finalize a separate rule making filed under WSR 15-24-129 for ground emergency medical transportation (GEMT) to implement HB 2007, subsection (10), Laws of 2015, 64th legislature, 2015 regular session, WAC 182-546-0150 and 182-546-0400 must be revised. HB 2007 (GEMT) required approval from the Centers for Medicare and Medicaid Services (CMS) before implementing. CMS approved the state plan amendment for GEMT (HB 2007) with the stipulation that the agency begin paying for all ground ambulance services through fee-for-service by January 1, 2018. This emergency fulfills that stipulation by removing references to managed care for ground ambulance services.
The agency filed WAC 182-546-0150 and 182-546-0400 under emergency rule making on December 21, 2017 (WSR 18-02-023) and began the permanent rule-making process. The agency completed the external stakeholder review and filed the proposed rule making under WSR 18-09-114 on April 18, 2018. The public hearing is scheduled for May 22, 2018. The emergency rules filed under WSR 18-02-023 are set to expire on April 20, 2018. This second emergency filing is required while the permanent rule-making process is completed. Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0. Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0. Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.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 2, 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 2, Repealed 0. Date Adopted: April 19, 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 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 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 in the WAH categorically needy/qualified medicare beneficiary (CN/QMB) and WAH 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 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 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 according to the agency's published medicaid provider guides and provider notices.
(4) Persons 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 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 with other insurance.
(6) The agency does not pay for ambulance services for jail inmates and persons living in a correctional facility, including persons 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 pay 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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