HEALTH CARE AUTHORITY
[Filed July 19, 2022, 11:26 a.m.]
Preproposal statement of inquiry was filed as WSR 21-11-027 [22-11-027].
Title of Rule and Other Identifying Information: WAC 182-502-0110 Conditions of payment and prior authorization requirements—Medicare coinsurance, copayments, and deductibles, and 182-500-0065 Definitions—L.
Hearing Location(s): On August 23, 2022, at 10:00 a.m. Until further notice, health care authority (HCA) continues to hold public hearings virtually without a physical meeting place. This promotes social distancing and the safety of the residents of Washington state.
To attend the virtual public hearing, you must register in advance https://us02web.zoom.us/webinar/register/WN_RT4WVYrRRrOZ6tCJOhN7YQ. If the link above opens with an error message, please try using a different browser. After registering, you will receive a confirmation email containing information about joining the public hearing.
Date of Intended Adoption: Not sooner than August 24, 2022.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email firstname.lastname@example.org, fax 360-586-9727, by August 23, 2022.
Assistance for Persons with Disabilities: Contact Johanna Larson, phone 360-725-1349, fax 360-586-9727, telecommunication[s] relay service 711, email email@example.com, by August 12, 2022.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: HCA is amending WAC 182-502-0110 to add that for long-term civil commitments, if medicare and medicaid cover the service, HCA pays the greater of medicare or medicaid's allowed amount, minus what medicare paid. Due to the amendment in WAC 182-502-0110, HCA is amending WAC 182-500-0065 to add a definition for long-term civil commitments.
Reasons Supporting Proposal: See purpose.
Rule is not necessitated by federal law, federal or state court decision.
Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: Not applicable.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Jason Crabbe, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-9563; Implementation and Enforcement: Abby Frazier-Cole, P.O. Box 45500, Olympia, WA 98504-5500, 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 proposed rule does not impose more-than-minor costs on businesses.
July 19, 2022
AMENDATORY SECTION(Amending WSR 19-02-046, filed 12/27/18, effective 1/27/19)
"Limitation extension" see WAC 182-501-0169.
"Limited casualty program (LCP)" means the medically needy (MN) program.
"Long-term civil commitment" means inpatient mental health treatment for clients on 90-day or 180-day court orders whose treatment is authorized by the agency in agency-contracted beds.
AMENDATORY SECTION(Amending WSR 17-06-063, filed 2/28/17, effective 3/31/17)
WAC 182-502-0110Conditions of payment and prior authorization requirements—Medicare 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:
(a) The deductible and coinsurance up to medicare or medicaid's allowed amount, whichever is less; or
(b) For long-term civil commitments, as defined in WAC 182-500-0065, the greater of medicare or medicaid's allowed amount, minus what medicare paid.
(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.